Need a brief refresher on the basics of what Healthcare Common Procedure Coding System (HCPCS) codes are and how they work? We’ve got you covered. Take a few minutes to brush up on the coding system with our HCPCS 101 guide.
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What is Healthcare Common Procedure Coding System (HCPCS)?
HCPCS stands for Healthcare Common Procedure Coding System. It is a set of standardized codes created and maintained by the Centers for Medicare & Medicaid Services (CMS) that represent medical procedures, supplies, products, and services.1
Why are HCPCS codes used?
HCPCS codes are used to facilitate the processing of health insurance claims. They make it possible to bill Medicare and other insurers for services such as drugs and biologicals, ambulance services, or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) used in outpatient settings.
How are HCPCS codes maintained?
HCPCS codes are maintained by CMS and are updated four times a year. The new codes are released quarterly in January, April, July, and October, and go into effect on the first of each month.
What do HCPCS codes look like?
HCPCS codes are five characters long and alphanumeric. They begin with a letter that corresponds with the chapter followed by four numbers. Some examples are:
- J9355: Injection, trastuzumab, excludes biosimilar, 10 mg
- C1823: Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads
What’s the difference between HCPCS and CPT?
The main differences between Current Procedural Terminology (CPT®) and HCPCS are in their code structure, purpose, and usage.
| CPT | HCPCS |
|---|---|
| Used to report medical, surgical, and diagnostic services performed by healthcare professionals | Represent products, supplies, and services. |
| Owned, maintained, and copyrighted by the American Medical Association (AMA) | Maintained by CMS and are in the public domain. |
| Five-digit numeric codes | Five-digit alphanumeric codes |
What are the “levels” of HCPCS?
HCPCS codes are divided into two primary levels, known as level I and level II.
Level I comprise CPT, a numeric coding system maintained by the AMA. Level I codes identify medical services and procedures performed by physicians or other health care professionals.
Level II HCPCS codes essentially report what providers used during a service (such as products and supplies), while Level I CPT codes describe what providers did during a medical encounter.1
How do HCPCS codes impact reimbursement?
When used in conjunction with CPT codes and ICD-10-CM codes, HCPCS codes can complete a billing claim representing all services provided to the patient.
The ICD-10-CM code provides the medical necessity for the service(s) provided (the CPT code) and the product(s) used (the HCPCS code) during the visit.
An example would be a patient with metastatic breast cancer who is seen at an outpatient chemotherapy infusion center for a PHESGO injection. The codes assigned would be:
ICD-10-CM:
- C50.41: Malignant neoplasm of upper-outer quadrant of breast, female
- C79.5: Secondary malignant neoplasm of bone and bone marrow
CPT:
- 96401: Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
HCPCS:
- J9316: Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg
Without the HCPCS code on the billing claim the facility would not receive reimbursement for the drugs and biologicals given to the patient.
Want to learn more about how HCPCS coding can boost OR scheduling, efficiency, and accuracy? Click here.
1HCPCS (HCPCS – Healthcare Common Procedure Coding System) – Synopsis. National Library of Medicine. No date listed. Accessed via: https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/HCPCS/index.html#:~:text=HCPCS%20is%20a%20collection%20of,by%20Medicare%20and%20other%20insurers
CPT is a registered trademark of the American Medical Association. All rights reserved.
