Insurance companies cover different healthcare services, but the patient’s eligibility or coverage is ensured or validated before any money is given out. These reimbursements heavily rely on reliable data and appropriate codes in medical claims. Medical coding translates data from a patient’s medical record into distinct codes. Medical billers employ a variety of medical coding systems, with CPT, HCPCS level II, and ICD-10 codes being the most often used.
What are HCPCS codes?
“HCPCS” is an abbreviation for “Healthcare Common Procedure Coding System.” Each year, CMS updates this list of codes. The HCPCS code set, as used in medical billing, refers to the national HCPCS Level II code sets. Healthcare professionals, doctors, and medical equipment suppliers use the HCPCS Level II code system.
This code set is used for billing for certain services when filing healthcare claims, including:
- Medical equipment
- Healthcare supplies
- Medications
- Transporting patients for medical reasons
- Additional goods and services
What is the purpose of HCPCS codes?
Healthcare professionals in the United States can utilize HCPCS codes to give uniform codes for medical treatments, supplies, and equipment. These codes add to the CPT codes used for outpatient billing by incorporating codes for operations carried out in hospitals and other inpatient settings.
Specific medical treatments, supplies, and equipment are identified and billed using these codes in medical billing. They aid in ensuring that healthcare providers are paid appropriately and fairly by insurance firms, Medicare, and Medicaid for their services. These codes allow providers to maintain correct billing records and adhere to legal regulations.
HCPCS code levels
The three tiers of HCPCS codes are as follows:
Grade I
The American Medical Association (AMA) maintains and publishes the CPT codes used in the healthcare industry, considered Level I codes. These codes list the treatments, operations, and diagnostic procedures doctors or other healthcare professionals do.
Grade II
This level includes non-physician treatments or procedures. Level II HCPCS codes denote the following services:
- Services for ambulances
- Wheelchairs
- Long-lasting medical supplies
- Additional health care services
Stage III
Lastly, level III HCPCS codes are regional and unrecognized nationwide. HCPCS Level III codes are alphanumeric codes with the letters X or Z as the first character.
HCPCS Modifiers
The Medicare & Medicaid Services (CMS) are responsible for updating and maintaining HCPCS level II codes and modifiers. Both of these modifiers—alphanumeric and two-letter—are used. The following are some examples of HCPCS level II modifiers:
E1 Modifier: This qualifier is used when a procedure is done on the upper left eyelid.
Modifier XS: The fact that a service was rendered on a different organ or structure makes it a separate system. This modification applies to surgical, non-surgical therapeutic, and diagnostic procedures that aren’t frequently encountered on the same day.
Modifier TC: When the two parts or segments of the operation are contained within one procedure code, this modification is used for billing the technical component (TC). If a doctor administers a test but does not interpret the results, the modifier TC should be used.
Examples of HCPCS codes
Coders can use the HCPCS Level I code 90716, which represents the delivery of varicella or chickenpox vaccination, to indicate the administration of the vaccine.
The HCPCS Level II code R0070 is an illustration of this. Coders use this code to demonstrate the delivery of staff and portable X-ray equipment to nursing homes or residences. When only one patient was serviced, coders should use this specific code.
The code R0075, which represents serving several patients, should be used if more than one patient was attended to.
What are the CPT codes in medical billing?
Current Procedural Terminology codes, sometimes called CPT, give healthcare professionals a particular language for billing medical treatments or procedures. CPT codes also improve efficiency and accuracy while streamlining reporting in addition to those benefits. AMA updates and publishes the CPT code set. For medical billing, these codes indicate a variety of medical treatments or procedures, such as:
- Surgical procedures
- diagnostic procedures
- Evaluations
- Additional treatments or services provided in medicine
The CPT code set includes thousands of codes that describe different medical treatments. The correct use of CPT codes is essential to medical billing. These codes have a detailed account of the action taken by the doctor, professional, or healthcare practitioner.
What are the CPT code categories?
In general, CPT codes fall into three categories:
First category
Medical coders most frequently use these category codes to submit services and procedures. The AMA revises the CPT codes every year. Only five-digit numeric codes fall under the category I. These numbers range from 00100 to 99499.
Six significant subcategories are further separated into this category as follows:
- Services for evaluation and management
- Medical services for anesthesia
- Surgical treatments
- Radiology procedures
- Diagnostic testing and pathology
- Medical treatments and procedures.
There are specific instructions on when and when to use each field of CPT code sets. The list of Category I subcategories and the accompanying code ranges are provided below:
- 00100-01999 – Anesthesia
- 10004-69990 – Surgery
- 70010-79999 – Radiology Techniques
- 80047-89398 – Laboratory Techniques and Pathology
- 90281-99607 –Services and Aspects of Medicine
- 99091-99499 – Management and Evaluation Services
Second category
These codes are used to gauge performance. Additional tracking numbers fall under category II. The four-digit alphanumeric codes in question all finish in “F.” For correct medical coding, these codes are optional. Hence, they are not necessary.
Codes in Category II fall between 0001F to 9007F.
- 0001F-0015F – Combined Measures
- 0500F-0584F – Patient Administration
- 1000F-1505F – Patient Background
- 2000F-2060F – Physical Evaluation
- 3006F-3776F – Processes or outcomes of diagnostic or screening
- 4000F-4563F – Interventions for treatment, prevention, or other purposes
- 5005F-5250F –Follow-up or Additional Results
- 6005F-6150F – Safety of Patients
- 7010F-7025F – Structural Modifications
- 9001F-9007F – Category II Codes for Non-Measures
Third category
Temporary codes for new methods, technologies, and services are included in this category. They have four digits and are alphanumeric codes, which terminate with a “T.” The category III codes span from 0042T to 0737T. Certain operations may be covered under Category I codes for the unlisted procedure.
On the other hand, you must use a code from Category III if it is present. For instance, the 0479T CPT code is used when: “The provider uses fractional ablative laser technology to cut apertures or windows (fenestrations) into burns and traumatic scars. Using this code, report the first 100 cm2 in adults or 1% of the body surface area (BSA) in babies and children.
- 0042T-0232T- Different Services – Category III Codes
- 0234T-0317T- Open or percutaneous atherectomy for supra-inguinal arteries and other undefined category codes
- 0329T-0358T- Images, Tests, Implants, and Other Services
- 0362T-0373T- Evaluations of Adaptive Behavior
- 0378T-0379T- Additional Methods and Evaluations
- 0394T-0422T- Lead-free and pocket-free pacemaker system
- 0424T-0465T- Operations involving the Phrenic Nerve Stimulation System
- 0469T-0478T- Image Analysis, Evaluation, Programming, and Recording Techniques
- 0479T-0480T- Techniques for Laser Ablation
- 0481T-0481T- Transfusion of blood components
What are the CPT modifiers?
CPT modifiers are made up of two characters, either alphanumeric or numeric. Modifiers, however, are most frequently employed as numbers, such as modifier 22, modifier 59, etc. The following are some of the most typical CPT modifiers:
Adapter 25
The phrase “significant, separately identifiable evaluation and management (E&M) services by the same physician or another healthcare physician on the same day of the procedure or other service” describes modifier 25 in medical billing.
26th Modifier
The term “professional component” (PC) refers to this Modifier. A doctor’s services may be part of this professional component, along with any oversight or interpretation of the test results provided by a technician. When doctors offer their services but have yet to run the test themselves, they should utilize modifier 26.
59th Modifier
In medical billing, a “distinct procedural service” is denoted by the modifier 59. In certain situations, a medical professional may be compelled to state that service was different from and unrelated to any other services rendered on the same day.
Nevertheless, the most frequently overused modifiers in medical billing are those including this word. When all other relevant modifiers have been exhausted, modifier 59 should only be utilized. Along with employing modifier 59 to support its use, i.e., highlighting that the services were rendered independently, documentation is also crucial.
What are the examples of CPT codes?
- 99214 might be used for a doctor’s appointment.
- If you are above 65, you can utilize 99397 for a preventative examination.
- The flu vaccination can be given using the number 90658.
- You can administer the varicella vaccination (90716) to prevent chickenpox.
- When a doctor sutures a 1-inch wound on your arm, the code 12002 can be utilized.
Key Differences between HCPCS Codes and CPT Codes
| Features | CPT Codes | HCPCS Codes |
| Importance | CPT codes are used for procedures, diagnostic procedures, evaluation and management services (E&M), and other services. | HCPCS codes are used for fundamental healthcare services like medical equipment and other supplies.With the help of these codes, the services are uniformly described. |
| Categories | They are separated into three groups, namely Groups I, II, and III. | They are separated into Level I, Level II, and Level III. |
| Produced or published by | AMA is in charge of publishing and maintaining. | The CMS (Centres for Medicare & Medicaid Services) publishes and keeps this information updated. |
| Objective or impact | These codes apply to the treatments and services patients receive from their healthcare practitioners. | Medical practitioners and non-frontend healthcare providers are both directly impacted by these codes. |
| Who may utilize it? | Outsiders are required to pay for the services to obtain the CPT codes. | Every person is allowed to use these codes for free. |
Conclusion
Accurate billing and legal compliance in the healthcare industry depend on adequately understanding and applying HCPCS and CPT codes. Although they have similarities, CPT codes are generally used for inpatient treatments, whereas HCPCS codes are used for medical equipment and supplies in outpatient and inpatient settings. Effective use of these codes is required to preserve accurate medical records, prevent claim denials, and guarantee quality patient care.