Are You Up-to-Date With HCPCS?


Vol. 17 •Issue 3 • Page 6
CCS Prep!

Are You Up-to-Date With HCPCS?

Besides ICD-9-CM and CPT, coders should be aware of HCPCS codes for 2007.

So you’ve reviewed the Coding Clinic, revised official coding guidelines, you’re becoming familiar with the new present on admission guidelines and got the new CPT codes. What’s left? Your responsibilities as a coding professional for being aware of all revised codes and their appropriate use don’t end there. You still need to review the HCPCS Level II codes for those that may represent invasive procedures and new technologies. In addition, questions may be drawn from any of the official coding systems for the certified coding specialist (CCS) and CCS-P (physician-based) examinations, and those preparing should be familiar with them.

One of the most difficult things about using these particular codes is that not all payers accept them. The Centers for Medicare and Medicaid Services (CMS) issues Transmittals indicating some HCPCS codes and their coverage policies, but not all payers follow Medicare guidelines. This is one reason that it’s imperative that the HIM coding department establish and maintain a good working relationship with the patient accounting/billing department in the hospital setting. Staff in those areas also need to be able to communicate with payers other than those in government, to ensure that the coding policies of each are clear. In some facilities and clinic/offices, it may make sense to create a billing and reporting matrix, which lists each payer and the types of codes each requires.

HCPCS Level II Codes

The Health Care Financing Administration (now CMS) developed HCPCS codes in 1983 to enable providers to consistently report procedures, professional services and supplies. Level II codes are considered national codes and if an appropriate HCPCS Level II code exists, it takes precedence over a CPT code for Medicare accounts and a significant number of state Medicaid systems. However, this may not be true for other payers, so coders must always be aware of the payer on outpatient accounts. Initially, HCPCS codes were most commonly reported via a facility’s charge description master but since the implementation of the outpatient prospective payment system (OPPS), more invasive procedures are represented by HCPCS codes, requiring HIM coding professionals to be aware of them. HCPCS codes are alphanumeric and include the following sections (not all-inclusive):

 

  • A codes: Transportation Services Including Ambulance; Medical and Surgical Supplies; Administrative, Miscellaneous and Investigational
  • B codes: Enteral and Parenteral Therapy
  • C codes: OPPS
  • G codes: Procedures/Professional Services (Temporary)
  • J codes: Drugs Administered Other than Oral Method; Chemotherapy Drugs
  • M codes: Medical Services
  • Q codes: (Temporary)
  • S codes: Temporary National Codes (Non-Medicare)
  • T codes: National T Codes Established for State Medicaid AgenciesAlthough coding professionals typically aren’t responsible for reporting all of these various types of services, they should be aware of them and should carefully review those sections that most often contain codes for invasive services and new technologies. CMS typically uses HCPCS temporary codes to determine the volumes and costs of new technologies for several years before moving to the process for assigning the services/technologies to final CPT codes. Coders in acute care facilities should be especially alert to codes in the C code, G code, Q code, S code and T code sections of HCPCS.

    Notable for 2007, new HCPCS codes are noted in Table 1 of the online version of this article, which can be found at www.advanceweb.com/him. CMS created codes G0392 and G0393 to specifically report PTA procedures performed on hemodialysis fistulas or grafts. When these services are provided to Medicare patients, these codes should be assigned instead of the CPT codes 35475 and 35476, which are still available to use when other clinical services are provided (e.g., on vessels unrelated to hemodialysis grafts) that are indexed to those codes. Note that code S2344 doesn’t have any corresponding APC assignment or reimbursement because the S codes are considered Non-Medicare and are used by the Blue Cross/Blue Shield Association and the Health Insurance Association of America for services when there are no national codes and codes are needed by the private sector to implement policies or claims processing procedures. In many cases, these services represent investigational procedures and are not eligible for reimbursement. Coding staff should ensure that payers accept these codes before assigning them.

    Although not new for 2007, coding professionals should be aware of the HCPCS codes in Table 2 of the online version of this article, which can be found at www.advanceweb.com/him. Ensure that if appropriate, these codes are assigned for Medicare cases in place of any corresponding CPT code. The list is not intended to be considered all-inclusive, nor should coders assume that all of the codes will be assigned by any particular provider. But it should serve as a starting point for HIM coding departments to use when determining when some of these new technologies are provided, that the appropriate codes are reported. It’s also the coders’ responsibility to stop reporting HCPCS codes when CMS has issued guidance related to using CPT codes instead. For example, in 2006 some HCPCS codes were required to be reported for infusion and injection services provided in hospitals. For 2007, the HCPCS codes are still valid, but for Medicare cases, codes from the 90765 Ð 90779 range should be assigned for these services. Typically, there is a logical progression of a new service being reported with a HCPCS code for several years and then being transitioned to a regular CPT code.

    The appropriate assignment of HCPCS codes also carries a significant amount of compliance and reimbursement risk. For example, if a Medicare patient has a dual chamber cardioverter defibrillator system placed, the appropriate code for the service is G0300, with corresponding reimbursement of $23,341. If the corresponding CPT code (33249) is assigned, the claim will be processed as an RTP (return to provider) because the code’s status indicator is “B:” Service not allowed under APCs. For a case that represents more than $23,000, it is important for most facilities to realize that reimbursement in as timely a manner as possible. Conversely, if a new service is provided to a non-Medicare patient that is reflected by an S code, that code should be reported (if accepted by the payer), regardless of reimbursement or coverage policies. Determination of whether one of these codes is reported or not should not be made by patient accounting or billing staff, based on coverage policy. This can lead to serious compliance risk if the provider realizes reimbursement for services that would not have been covered or reimbursed if the more appropriate HCPCS code had been reported.

    While review of new and revised CPT codes is still a very important activity required of every coder, the review of HCPCS Level II codes should be considered an imperative as well. Research and review of Medicare Transmittals related to these codes should also be considered an essential component of outpatient coding and reporting.

  • Test your knowledge of HCPCS code reporting with the following quiz:

    1. HCPCS codes are used to report new technologies and if a code is available to represent a certain service, it will be reimbursed by the payer.

    a. True

    b. False

    2. A 69-year-old male Medicare patient was seen in the hospital outpatient surgery area for prostatic malignancy. He was treated with prostate brachytherapy, including implantation of 72 iodine-125 seeds. The appropriate CPT code(s) is/are:

    a. G0261, C1718

    b. 55859, 77778, C1718 X 72

    c. G0261

    d. 55859

    3. A 33-year-old newly diagnosed ESRD patient with Aetna insurance was seen in the hospital’s outpatient surgery area for treatment of an obstructed hemodialysis AV graft. She was treated with percutaneous transluminal balloon angioplasty of the venous portion of the graft with good response. The appropriate CPT code(s) is/are:

    a. 35476, 75978

    b. G0393

    c. 35460

    d. 35875, 75978

    4. A 91-year-old female Medicare patient was seen in the Audiology Clinic for function tests. She had a comprehensive threshold evaluation performed, along with a speech recognition test. To perform these tests, the physician first had to remove impacted cerumen from the canals of both ears. The appropriate CPT code(s) is/are:

    a. 69210, 92557

    b. 69210, 92553, 92556

    c. 92557, G0268

    d. 92553, 92556, G0268

    Coding Clinic is published quarterly by the AHA. CPT is a registered trademark of the AMA.

    This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

    Answers to CCS Prep!: 1. b. False. There is no guarantee that any particular service will be reimbursed, regardless of its code assignment. In many cases, CMS and other payers track the volume, distribution and costs of a particular service for several years before making final coverage decisions; 2. b. In the past, CMS has required hospitals to report codes G0256 or G0261 for prostate brachytherapy services, but at the present time the service is reported with code 55859 for the surgical procedure, 77778 for complex placement of the brachytherapy seeds (> 10 is considered complex) and C1718 X 72 service units for the brachytherapy seeds themselves; 3. a. This case is not a Medicare account, so HCPCS codes should not be reported unless specifically instructed to do so by the payer. The procedure involved a percutaneous approach so code 35460 is invalid because it specifies an open approach. Similarly, code 35875 is inappropriate because it references a procedure on a vessel that doesn’t involve a hemodialysis graft. Codes 35476 and 75978 are most appropriate to report both the surgical component and the radiological supervision and interpretation component of the procedure; 4. c. Code 92557 is assigned for the combined comprehensive audiometry threshold evaluation and the speech recognition tests. CMS instructs that when impacted cerumen is removed on a patient on the same day as audiologic function testing, that HCPCS code G0268 should be reported instead of CPT code 69210.