A Guide to HCPCS Codes

September 11, 2012

Here is what your medical practice needs to know about HCPCS codes, where they fit with CPT codes, and how to understand them.

For many medical practices, CPT codes describe the majority of services performed and reported by their clinicians. So, it is tempting to ignore the Healthcare Common Procedure Code Set (HCPCS) and simply buy new CPT and ICD-9 books each year. But, what are HCPCS codes and why must a medical practice know and understand them? HCPCS codes are Category II procedure codes developed by the CMS to describe a medical service or supply. Category I codes are CPT codes, developed and copyrighted by the American Medical Association.

The HCPCS book, which is updated annually by CMS, includes codes for durable medical equipment, orthotics, ambulance services, supplies, medications, dental procedures, and services provided under the Outpatient Prospective Payment System (OPPS). There are also national codes developed by CMS to identify procedures or professional services on a temporary basis or preventive services. HCPCS also includes behavioral health codes used by some state Medicaid programs.

Some Quality Data Codes used to report on the Physician Quality Reporting System are HCPCS codes. There are HCPCS codes to describe cast supplies and some temporary codes established by private payers. In this instance, the use of the word "temporary" can be misleading. Some HCPCS codes are longstanding codes developed by Medicare to describe a service that is similar to or the same as a CPT code.

CMS uses the code to differentiate between a preventive service and a therapeutic or diagnostic service. For example, CMS describes the administration of flu vaccines with a HCPCS code instead of a CPT code. CMS also uses a HCPCS code to describe a screening colonoscopy, even though there is a CPT code for screening colonoscopy. In these cases, the codes are not so much temporary as differentiating.

There are also HCPCS modifiers, which a practice may use. CPT develops two-digit numeric modifiers, described in Appendix A in the CPT book. CMS develops two-digit alpha-numeric or alphabetical modifiers to report that a service or procedure has been altered by specific circumstances, but these do not change the description of the CPT or HCPCS code that is reported. Both CPT and HCPCS modifiers may be used on either CPT or HCPCS codes.

Some modifiers are informational, and do not change payment. For example, the GC modifier tells Medicare that the service was jointly performed by a teaching physician and resident. The payment amount does not change, but the modifier is required for jointly provided services performed by a resident and attending. There are modifiers for body location (digits, eyelids, right, left) that provide information to the payer and prevent incorrect denials. Medical practices need a complete, up-to-date listing of HCPCS modifiers, found in the HCPCS book.

Medical practices that purchase medications for injections or infusions need to pay special attention to the HCPCS section on medications. These codes, which start with the letter J, list the medication and the number of milligrams, grams, micrograms, or milliliters. For any injections or infusions the practice performs, review what constitutes one unit. Be sure that the dosage given and documented in the record is correctly described by the units as defined by HCPCS.

All medical practices need an up-to-date version of a HCPCS book in order to accurately report services performed by their clinicians.

Betsy Nicoletti is the founder of Codapedia.com. She is the author of "A Field Guide to Physician Coding." She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at betsy.nicoletti@gmail.com or 802 885 5641.