Good Morning,
I would like to take a moment to introduce myself and provide an overview of the Alpha-Numeric HCPCS coding process. I am Carolyn Kaye Riley and I coordinate the Alpha-Numeric HCPCS activities at the Health Care Financing Administration (HCFA). I Chair the HCFA HCPCS Workgroup and represent HCFA on the HCPCS National Panel. I also serve as the Chairperson of the HCPCS National Panel.
HCPCS is an acronym for the Health Care Financing Administration Common Procedure coding system. It is a national coding system used to describe physician, and non-physician services, procedures, health care products and supplies. The codes are used by Medicare, Medicaid, public, and private insurance programs in their claims processing systems to screen billed services. HCPCS includes three levels of codes as well as modifiers: Level I - CPT(Current Procedural Terminology) codes, Level II - national alpha-numeric codes, and Level III - local Medicare codes.
Level I HCPCS /CPT codes are owned, managed and copyrighted by the American Medical Association (AMA). They consist of 5 position numeric codes and associated terminology that describes specific professional services and procedures. The AMA has entered into an agreement with HCFA which states: The AMA permits HCFA, its agents, and other entities participating in programs administered by HCFA to use CPT codes/modifiers and terminology as part of HCPCS. Other public and private sector payers enter into licensing agreements with AMA and also use CPT codes in their programs.
Developing and maintaining the CPT codes is the responsibility of the American Medical Association and all proposed additions to, or modifications of the CPT codes are made by the decision of the CPT Editorial Panel. Correspondence to request an application for coding change should be directed to: CPT Editorial Research & Development, American Medical Association, 515 North State Street, Chicago, Illinois 60610. The Internet site for the AMA is http://www.ama-assn.org .
Level II /Alpha-Numeric HCPCS are 5 position codes with an alpha character as the first digit followed by four numbers and associated with specified nomenclature. They are used to supplement CPT codes and identify professional services and procedures, which are not included in CPT/Level I HCPCS. They also contain codes for ambulance, audiology, physical therapy, speech pathology and vision care, and such supplies as drugs, durable medical equipment, orthotics, prosthetics and other medical and surgical supplies.
Coding decisions related to the Level II HCPCS National Codes, descriptors, and Modifiers, which begin with the letters “A, B, E, H, J, L, M, P, R, and V”, are made by the National Panel. The HCPCS National Panel is comprised of representatives from the Blue Cross/Blue Shield Association of America (BCBSA), the Health Insurance Association of America (HIAA), and the Health Care Financing Administration (HCFA).
Coding requests may be submitted at anytime throughout the year through the Level II Alpha- Numeric HCPCS Modification process. Information related to the process as well as a copy of the recommendation format may be downloaded from the Internet at the following web site: www.hcfa.gov/medicare/hcpcs.htm
The Alpha-Numeric HCPCS national code request forms must be submitted each year by April 1st to be reviewed and considered for the following January 1st HCPCS update. The Level II codes and modifiers and their descriptors are approved and maintained jointly by the Alpha-Numeric HCPCS National Panel. The Panel mails out decision letters in response to the HCPCS coding requests. They are mailed out in October but always before November 15th each year. The HCPCS database (not including the “D” codes) is updated once each year and posted on the web page (www.hcfa.gov/stats/pufiles.htm#alphanu ) in October with changes effective January 1st.
The “D” codes are copyrighted by the American Dental Association. They are updated by ADA every 5 years and they are not included in the HCPCS posted on the Internet. They do appear on the computer tape available from NTIS (800-553-6847 or visit www.ntis.gov to order the 2000 HCPCS Tape, stock number: PB2000-500018, or to order the diskette stock number PB2000-100286) and in the paper copy available through the government printing office (202-512-1800 or visit www.gpo.gov to order the 2000 Alpha-Numeric HCPCS Paper version – stock number 017-060-00620-0).
The “D” codes or D section of the Alpha-numeric HCPCS have been provided under an agreement with the American Dental Association (ADA) permitting HCFA, its agents, and other entities participating in programs administered by HCFA, to use the ADA Current Dental Terminology Third Edition (CDT-3)/The Code on Dental Procedures and Nomenclature- The Dental Code (“The Code”) as part of HCPCS. An amended licensing agreement is currently being developed to permit expanded use of the ADA copyrighted “D” codes by Medicaid State Agencies. The ADA Council on Dental Benefit Programs is responsible for developing and maintaining “The Code.” Dentists wishing to submit new code requests for review may call the ADA’s Council on Dental Benefit Programs at 800-621-8099, extension 2753 or visit their web site http://www.ada.org/P&S/benefits/cdtguide.html .
The “J” codes or J section of the Alpha-Numeric Level II HCPCS are national codes established by the HCPCS National Panel to identify generic drug categories. All requests submitted to the National panel for review for a “J” code must contain a copy of the FDA approval letter (NDC codes http://www.fda.gov/cder/ndc/index.htm ) and the drug must have been on the market for six months after the FDA approval and prior to submitting the coding request.
The “C, G, K and Q” code sections of the alpha-numeric HCPCS have been designated by the national panel for HCFA use, to establish codes needed to identify professional services, procedure, products or supplies and to implement specific Medicare or Medicaid policies. These HCFA codes have previously been identified as “temporary codes.” Many of the codes, established to implement the Medicare programs, are used by other insurers and may be converted to national codes but others will remain HCFA codes forever, for example, the “Q” codes for administration of EPO in ESRD facilities are used exclusively by Medicare.
The “C” code section has recently been established to permit implementation of Section 201 of the Balanced Budget Act of 1999 (BBRA). The "C" codes will be used to identify items for the Hospital Outpatient Prospective Payment System (HOPPS). These codes are product specific and will only be valid for Medicare on claims submitted by the hospital outpatient departments. Any other use on Medicare claims will be identified as “not valid.”
The “K” codes have been established for use by the Durable Medical Equipment Regional Carriers (DEMERC). The “G” codes are assigned by HCFA to identify procedures, and professional services. The “Q” section contains codes for drug, and biologicals, and other unspecified medical supplies not identified by the national “permanent” codes but needed based on Medicare internal operating needs. The HCFA coding decisions are made through the HCFA HCPCS Coding Process. The HCFA temporary codes and effective dates for use are posted on the HCFA web site.
The “S, and I” sections of the Level II/Alpha-Numeric HCPCS have been designated for use by the private sector by the HCPCS National Panel. The “S” codes were first published in the 2000 HCPCS Update. They have been established by the private sector based on the private sector internal operating needs, for the implementation of private sector policies, programs, and/or claim processing. The “S” codes identify products, supplies, professional services and procedures that do not appear in the national permanent Level I or Level II codes.
At this time, there are no codes in the “F, H, I, N, O, T, or U” sections of the alpha-numeric HCPCS.
Modifiers – HCPCS contain Level I, Level II, and Level III modifiers. Modifiers are 2 position codes and descriptors used to indicate that the service or procedure which has been performed or provided was altered by some specific circumstance but did not change the original description or its 5 position code. The modifiers are grouped by the three levels. The WA through ZZ range of modifiers has been reserved for Level III/Local codes. The “G, K & Q” modifiers are reserved for HCFA/ Level II. The remainder of the alpha-numeric and numeric series is reserved for national HCPCS modifiers and AMA modifiers, respectively (Level I and Level II).
Level III HCPCS/Local Codes and descriptors developed for Medicare Carriers for use at the Local carrier level. They are 5 position alpha-numeric codes in the “W, X, Y and Z” series. They represent professional services and procedures, products and supplies that are not represented in the Level I or Level II codes. Historically, when Medicare Contractors identified the need for a Local Code, they were instructed to submit their request with supporting documentation to their HCFA Regional Office (MCM 4507.1). The Regional Office would determine if other contractors in that region also had a similar need. In turn the Regional Office would submit the request for a local code to HCFA Central Office for review and coding decision by the HCFA HCPCS Workgroup. I am happy to report that only 2 local code requests have been submitted in the last 12 months, with only one found to justify the establishment of a short term local code.
Several years ago when Medicare was planning to implement a system of nationally uniform claims processing software (the Medicare Transaction System (MTS)), instructions went out to all the Medicare contractors asking that they review their local coding practices and strive to eliminate as many local codes as possible. We were asking them to assist us in standardizing the code sets so that all the contractor operating systems would use the same set of codes. We asked that they: 1) eliminate all the local codes that duplicated national codes, 2) eliminate all the local codes that had not been used in the last 18 months, 3) to eliminate all the local codes that represented specific brand name products and to identify the general product category that would describe the products, 4) to identify and remove from the list of HCPCS codes, any codes that had been established strictly for internal operating needs, never published, and never appear on a claim form. (These codes did not actually qualify as HCPCS codes but they could still be used internally just as the HCFA mailstops or routing codes are used to move mail from one place to another.), 5) To identify codes that could be identified/coded through other fields, such as, place of service, or by ICD-9 diagnosis codes on a line other than the HCPCS code line on the claim form. That effort greatly reduced the number of Medicare contractor local codes – the printout of the local codes in 1995 would fill a 4 inch thick binder. The 2000 HCPCS Local code printout is less than a 1/4 inch thick. It contains many blank spaces and pages and some codes as well as modifiers without complete descriptors. These will be discontinued.
I am asking that all the Regional Offices again petition the Medicare contractors to begin now to reduce or eliminate the remaining local codes and to use national codes or modifiers. As you can see, the effort to reduce local codes for the Medicare contractors is working. For example, Region V recently reported that after working with the contractors in the region and asking that they again review the local codes, they were able to eliminate 122 codes and 62 modifiers. The contractors will be instructed to closely review the 2001 HCPCS update and strive to eliminate as many of the remaining local codes as possible.
If any codes remain they will be instructed to prepare national coding modification requests with documentation to support their request, such as: number of claims involved, frequency of use, dollar amounts implicated. They will need to provide a full explanation of how the code is used and why it is needed, and then to submit the request with documentation to the regional office for review. The RO will then determine if the code is needed by other contractors in the region. The RO will then present the final coding request to HCFA Central Office, HCFA HCPCS Workgroup, for review and coding decision or for recommendation to the National Panel for a National Code.
Speaking of Local Codes, I have been working with the Medicaid bureau in HCFA Central Office and communicating with the Medicaid State Agencies via telephone conference calls, in an effort to assist with the major task of moving toward the elimination of the Local Codes used by the Medicaid State Agencies. They have developed a plan and are putting it into action. When they have identified a prioritized list of codes that will meet the needs of the State Agencies, they will be instructed to submit the request with supporting documentation through HCFA Central Office Medicaid Bureau for review. Central Office will coordinate the preparation and submission of the request to the HCFA HCPCS Workgroup for review and coding decisions or for recommendation to the National Panel for National Codes. We anticipate that this will initially be a major task but once the bulk of the codes have been identified the State Agencies can then coordinate any subsequent coding requests through the Medicaid Bureau for submission through the regular HCFA HCPCS Workgroup and National Panel coding process.
In Summation: The Alpha-Numeric Coding process is evolving and many changes are occurring. In October of 1998 we placed the HCPCS file (without the “D” codes) on the Internet – Free to the Public - to view and/or download if they wish. We established a HCPCS Internet Web site http://www.hcfa.gov/medicare/hcpcs.htm. Thus providing another link to the Alpha-Numeric HCPCS code set. Providing easy access, with no waiting time to obtain a copy of the HCPCS Coding Modification information packet and request form. The HCPCS National Panel agenda, the tracking number and all the coding requests, as received, are posted permitting an opportunity for public review and public comment.
The Internet web site increases public awareness of the items submitted for review and coding consideration. The web site also includes a list of various sources for obtaining paper and electronic version of the 2000 HCPCS Update, as well as list of sources for the
2000 Medicare Fee Schedule Information. We have also included a list of the “temporary” HCFA HCPCS codes established for use this year. For those with questions and or comments regarding the Alpha-Numeric HCPCS coding process, we have established a direct electronic link – HCPCS@hcfa.gov .
I anticipate that the Medicare Manual section 4501 will be revised and the local code mechanism revised to reflect a HCFA “temporary” coding process with the assistance of the Medicare Regional Offices and the Medicaid Bureau in HCFA Central Office.
The National Code Sets have been identified and each code set has an established maintenance and updating procedure in place. Both Public and Private insurers must work together, make necessary changes, plan and take immediate action to support and use the national standard code sets. Remember! When people speak of the standardization of Local Codes, they actually mean "THE USE OF NATIONAL CODES."