Question

9. How does an individual or group (such as a provider) get a HCPCS code added, changed, or deleted?

Answer 1

Healthcare Common Procedure Coding System (HCPCS), commonly pronounced “hicks-picks.”The Centers developed HCPCS for Medicare and Medicaid (CMS) for the same reasons that the AMA developed CPT: reporting medical procedures and services.

The code set is divided into three levels:

• Level one is identical to CPT, though technically, those codes, when used to bill Medicare or Medicaid, are HCPCS codes.

• Level II HCPCS codes are designed to represent non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that don’t fit readily into Level I.

THERE ARE TWO AGENCIES THAT ISSUES HCPCS CODING:

• The Centers for Medicare & Medicaid Services (CMS), located in Baltimore, Maryland, is the agency that issues new HCPCS codes. CMS uses an HCPCS Workgroup to make its decisions on new codes.

• • The Pricing Data Analysis and Coding (PDAC), a CMS contractor in Fargo, North Dakota, has the responsibility to determine the appropriate HCPCS code through a coding verification process. This process is used when a company believes that its product already falls under an existing HCPCS code and needs written verification from the PDAC. It is also used by companies who believe that they have a unique product and want verification of that before they would apply a new HCPCS code to CMS

SOME FACTORS NEEDED TO TAKE CONSIDERATION WHILE MAKING CODING STRATEGY:

• Has the product gone through the FDA regulatory process, or does it need to do so? Will the FDA code designation impact which HCPCS code will be assigned to your product?

• In what site of service do you intend to market your product? Where will your customers use the product? Which coding system (CPT or HCPCS) applies to your product?

• Does an HCPCS code for a similar product already exist? Does your product fit under the existing HCPCS code?

• Does your product need a new HCPCS code? What is the linkage, if any, between coding, payment, and coverage for the product?

FORGETTING NEW HCPCS CODE COMPANY SHOULD:

• A company completes the HCPCS code application and, for the most part, the CMS HCPCS Workgroup issues a brand-specific code for the CTP.

• Timing HCPCS code applications are accepted throughout the year, but the deadline for each year is the first week in January.

• Applications received after the deadline will be declined, and the applicant should resubmit to a subsequent coding cycle. Applications received by the deadline determined to be incomplete will also be declined, and the applicant should submit a completed application in a subsequent coding cycle.

• The HCPCS code application can be found on the CMS website. By completing this, the company can ask to establish, revise, or discontinue an HCPCS code via the HCPCS code application.

• As part of the application, the applicant should also submit any descriptive material, including the manufacturer's product literature and information that the applicant thinks would help further CMS’s understanding of the item's medical features for which a coding revision is requested.

• When the company establishes its reimbursement strategy, the company needs to review the HCPCS coding application and the HCPCS Workgroup criteria to establish a new HCPCS.

• HCPCS code modifiers are established internally by CMS to facilitate accurate Medicare claims processing. Modifiers are assigned for use when the information provided by an HCPCS code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service.