Medicare 101: Part 4:
“The Procedural Coding System”
Part B Provider Outreach and Education
February 4, 2014
Revision 02.04.14
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DISCLAIMER
This resource is not a legal document. This presentation was prepared
as a tool to assist our providers. This presentation was current at the
time it was created. Although every reasonable effort has been made
to assure accurate information, responsibility for correct claims
submission lies with the provider of services. Reproduction of this
material for profit is prohibited.
CPT Disclaimer American Medical Association (AMA)
Notice and Disclaimer
Current Procedural Terminology (CPT) only copyright ©2013 American
Medical Association. All rights reserved. CPT® is a registered
trademark of the American Medical Association (AMA). Applicable
FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors, and/or related components are
not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly
practice medicine or dispense medical services. The AMA assumes no
liability for data contained or not contained herein.
Agenda
• Medicare Coding System Background
oHCPCS Level Code Sets
• Coding Manuals and Tools
• Medicare Updates
• Resources
Back to
the
Basics
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Background
• Health Care Common Procedure Coding System
(HCPCS)
o Divided into two principal subsystems
o Referred to as Level I and Level II
• Level I code set known as the HCPCS numeric
coding system (comprised of Current Procedural
Terminology (CPT-4)
• Level II code set known as the HCPCS alphanumeric procedure codes
• Goal = Standardization of Coding Systems
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Current Procedural Terminology (CPT)
(Level I HCPCS)
• Developed in 1966
• Maintained by the American Medical Association
(AMA)
• For reporting medical services and procedures
o Performed by physicians, non-physician practitioners and
suppliers
• Provides uniform language to describe medical,
surgical and diagnostic services
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CPT Manual
• Providers can find quick reference guides for:
o Symbols used in the CPT manual
o Illustrated anatomical and procedural review
o Commonly billed modifiers (definitions located in
Appendix A)
o Place of Service Codes and their descriptions
 Available in the inside cover pages
*Based on the CPT-4 Standard Edition
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CPT Manual
• Section Numbers and their Sequences
• Divided into 6 main sections
*Based on the CPT-4 Standard Edition
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CPT Manual
• You will also find the:
– Category II codes – set of tracking codes used for
performance measurement
• Codes described with 4 digits followed by the letter
“F”
– Category III codes – contains a set of temporary
codes for emerging technology, services and
procedures
• Codes described with 4 digits followed by the letter
“T”
*Based on the CPT-4 Standard Edition
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CPT Manual
Appendix Listing
Appendix A
Modifiers
Appendix B
Summary of Additions, deletions and revisions
Appendix C
Clinical examples of E & M services
Appendix D
Summary of CPT add-on codes
Appendix E
Summary of CPT codes exempt from Modifier 51
Appendix F
Summary of CPT codes exempt from Modifier 63
Appendix G
Summary of CPT codes that include moderate (conscious)
sedation
Appendix H
Alphabetical clinical topics listing
*Based on the CPT-4 Standard Edition
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CPT Manual
Appendix Listing
Appendix I
Genetic testing code modifiers
Appendix J
Electrodiagnostic medicine listing
Appendix K
Product pending FDA approved
Appendix L
Vascular families
Appendix M
Deleted CPT codes
Appendix N
Summary of resequenced CPT codes
Appendix O
Multianalyte assays with algorithmic analyses
*Based on the CPT-4 Standard Edition
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Instructions for Use of CPT
• Select code that most accurately identifies service
performed
• If no procedure code exists, report appropriate
“unlisted” code
• Medical record documentation must support service
billed
• Must bill using code that is valid for date of service
*Based on the CPT-4 Standard Edition
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Add-on Codes
• Describe additional intra-service work associated with
primary procedure
• Codes must be reported with primary procedure
o Never reported as a stand-alone code
• Add-on codes apply only to services performed by
same physician
• Designated by the symbol
• Also listed in Appendix D of CPT
*Based on the CPT-4 Standard Edition
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Add-On Code Example
• 11200 – Removal of skin tags, multiple
fibrocutaneous tags, any area; up to and
including 15 lesions
• 11201- each additional 10 lesions, or part
thereof
• Hint: Look for the statement “List separately in
addition to code for primary procedure “
*Based on the CPT-4 Standard Edition
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Unlisted Procedure Codes
• Used to report services or procedures not found in
CPT manual when:
– A procedure does not yet have an assigned code
– The service performed is a variation of a defined
procedure code
• Unlisted codes are found in the guideline sections for
E&M, Surgery and Medicine
*Based on the CPT-4 Standard Edition
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Unlisted Procedure Codes
• Service represented by unlisted procedure code must
be described on claim
– Paper claim, in Item 19 of CMS 1500 form
– Electronic claim, in narrative or free-form field
Give explanation or narrative for service
64999
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Alpha-Numeric HCPCS Codes
(Level II HCPCS)
• Developed in 1983
• Maintained by the Centers for Medicare and
Medicaid Services (CMS)
• Billing of services/procedures not in CPT
– Primarily supplies, materials and injections
– Ambulance services
*Based on the HCPCS Level II Professional
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Alpha-Numeric HCPCS Codes
Instructions
• Identify the services or procedures
• Look up the appropriate term
• Assign the appropriate code
*Based on the HCPCS Level II Professional
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Alpha-Numeric HCPCS Manual
• Introduction
o Commonly used symbols and definitions
o Index organized by description and alpha-numeric
codes
o Categories of procedures, services and supplies
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Alpha-Numeric HCPCS Manual
Alpha-Numeric Listing
Category
HCPCS Sequence
Transportation Services
A0000 – A0999
Medical & Surgical Services
A4000 – A8999
Procedures & Professional Services
(temporary)
G0008 – G9147
Drugs (other than oral)
J0000 – J8999
Chemotherapy drugs
J9000 – J9999
Medical Services
M0064 – M0301
Pathology & Laboratory services
P2028 – P9615
Q codes
Q0035 – Q9968
*Based on the HCPCS Level II Professional
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Alpha-Numeric HCPCS Manual
Appendix
Appendix 1
Table of drugs
Appendix 2
Appendix 3
Appendix 4
Modifiers (alpha-numeric)
Abbreviations/Acronyms
Publication 100 References
(CMS Internet Only Manual)
Appendix 5
New, Changed, Deleted &
Reinstated
Appendix 6
Place of Service
*Based on the HCPCS Level II Professional
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Procedural Coding Tools
• Medicare Physician Fee Schedule Database
(MPFSDB) File
• National Correct Coding Initiative (NCCI) Edits
• Durable Medical Equipment (DME) Jurisdictional
Chart
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MPFS Database File
The MPFSDB is the acronym for the Medicare Physician
Fee Schedule Database. It is also known as the
Relative File.
• Affects payment profile
• Changes are made quarterly
• CMS controls the edit process
• File has over 10,000 physician services which contain
the associated relative value units (RVUs), fee
schedule status indicators, and various payment
policy indicators (i.e., payment of assistant at surgery,
bilateral surgery)
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Common MPFSDB Denials
Status Indicators
• Status indicators is a category listed on the MPFSDB file
• The indicator description will provide details when (not an allinclusive list)
– A code is deemed active
– Bundled for payment
– Carrier-priced procedure
• Procedure codes are most commonly denied when they have a
status indicator of
–
–
–
–
B = Bundled code
D = Deleted codes
I = Code is not valid for Medicare purposes
N = Non-covered services
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Where to Locate the MPFS File
Cahaba GBA Website
• Visit the Cahaba GBA website at
www.cahabagba.com
• From the Home Page go to Part B Quick Links
• Click on the Schedules and select the appropriate
year
– Print and copy the MPFSDB Indicator File
Descriptors ; and,
– Download the National MPFS Relative Value File
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Where to Locate the MPFS File
CMS Website
http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html
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National Correct Coding Initiative (NCCI)
• Edits within the claim processing systems for dates of
service on or after January 1, 1996
• Implemented to prevent improper payment when
incorrect code combinations are reported
• Based on coding conventions defined in the
– AMA’s CPT manual, national and local policies,
coding guidelines developed by national societies,
etc.
• NCCI updates are made quarterly
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National Correct Coding Combination
• The NCCI file consist of the Column One/Column
Two coding edits
• Part B providers use the “Physician CCI Edits”
searchable database
• CMS has created a manual titled “How to Use the
Medicare NCCI Tools”
• Dedicated NCCI website located at
http://cms.gov/Medicare/Coding/NationalCorrectCodI
nitEd/index.html
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Change Request 7501 – NCCI Add-On
Codes
• Effective date: January 1, 2014
• Implementation date: January 1, 2014
• Define add-on codes in three ways:
– Code is listed in CR7501 or as a Type I, Type II or
Type III add-on code
– Listed on the MPFS with a global surgery period of
“ZZZ”
– CPT Manual designated by the symbol “+”
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Change Request 7501 – NCCI Add-On
Codes
• CMS has divided the add-on codes into three groups
– Type I: Limited number of identifiable primary
procedure codes
– Type II: Does not have a specific list of primary
codes
– Type III: Some specific primary procedure codes
identified in the CPT manual
• CMS will update the list annually on January 1
• Quarterly updates will be posted as necessary on
April 1, July 1 and October 1 each year
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http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html
2014 Durable Medical Equipment HCPCS
Jurisdiction List
• A chart which lists HCPCS codes to determine the responsible
contractor to bill DME related services
• It will include the HCPCS, description and jurisdiction
• 2013 DMEPOS Jurisdiction List is located at
http://www.cahabagba.com/part-b/claims-2/durable-medical-equipmentdme-jurisdictional-chart/
HCPCS
Description
Jurisdiction
A0021 - A0999
Ambulance Services
Local Carrier
A4206 - A4209
Medical, Surgical, and SelfAdministered Injection Supplies
Local Carrier if incident to a physician's
service (not separately payable). If other,
DME MAC.
A4210
Needle Free Injection Device
DME MAC
A4211
Medical, Surgical, and SelfAdministered Injection Supplies
Local Carrier if incident to a physician's
service (not separately payable). If other,
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DME MAC.
*This is not an all-inclusive list
Claim Submission Errors
Procedure Codes
• Providers should be mindful to avoid the following:
– Procedure codes that are deleted or invalid for
Medicare purposes
– Submitting claims with a transposed codes
– Appending the incorrect modifier
– Procedure codes billed with the wrong place of
service
– Codes submitted to Medicare Part B in error
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Claim Submission Error Example
• Incorrect
01 17
14
21
99212
11
99212
• Correct
01 17
14
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Claim Submission Error Example
• Incorrect
01
27
14
21
71020
21
71020
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• Correct
01
27
14
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Comprehensive Error Rate Testing
• CERT Task Force created
• Part A/B Medicare Administrative Contractors joined
forces in 2013
• Educational strategy will select one to four national
CERT “hot topics”
• Visit our
webpage on the Cahaba GBA
website
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HCPCS Release Information
National Technical Information System (NTIS)
Call NTIS at 1-800-553-6847 or visit www.ntis.gov to order the following:
2014 Alpha-Numeric HCPCS on CD-ROM (including paper documentation)
Stock number: PB2014-500006
CPT-4 Code Information
Contact the American Medical Association:
Telephone number 1-800-621-8335
Visit the AMA store via their website at http://www.ama-assn.org/ama
HCPCS manuals can be found at your local bookstore
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Medicare Resources
HCPCS Release & Code Sets found on the CMS website at
http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
/index.html
Stay up to date with the latest Remittance Advice Reason
and Remark codes from the Washington Publishing Company
http://www.wpc-edi.com/reference/
Search the Cahaba GBA website for General Medicare
Billing references at https://www.cahabagba.com/partb/education/general-billing-information-2/
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CMS Internet Only Manual
• CMS Manual System, Pub 100-4, Medicare Claims Processing
Manual, Chapter 23, Fee Schedule Administration and Coding
Requirements
• CMS Manual System, Pub 100-4, Medicare Claims Processing
Manual, Chapter 23, Section 20, Healthcare Common
Procedure Coding System (HCPCS)
• CMS Manual System, Pub 100-9, Medicare Contractor
Beneficiary and Provider Communications Manual, Chapter 6,
Section 30.1.1, Responding to Coding Questions
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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html
Acronyms
Participants can view a list of acronyms used
during today’s webinar by accessing the
glossary section on the Cahaba GBA website,
www.cahabagba.com
Questions?
Provider Contact Center: 1-877-567-7271
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