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HCPCS Level II And How it Relates to your Physical Therapy Practice

StrataPT,

Every year, health care insurers in the United States process over 5 billion claims for payment.  As staggering as that statistic is, that number will most likely continue to rise. In order for Medicare and other health insurance programs to process these claims in an orderly and consistent manner, a standardized coding system is essential.

HCPCS Level II codes are used for billing Medicare and Medicaid patients, as well as some third-party payers, and are extending to a wider array of medical services.  HCPCS (pronounced hic-pics) stands for the Healthcare Common procedure Coding System and are updated and published annually by the Centers for Medicare and Medicaid Services (CMS).  These codes supplement the CPT coding system by including codes for nonphysical services, administration of injectable drugs, durable medical equipment (DME) as well as office supplies.

HCPCS Level I is the American Medical Association’s (AMA) Physicians’ Current Procedural Terminology (CPT) coding system and is numeric.  HCPCS Level II codes are alphanumeric.

There are several important aspects to keep in mind when using the HCPCS Level II codes:

  1. Unfortunately, CMS does not use consistent terminology for unlisted services or procedures. Therefore, the code descriptions may include any of the following terms:
    • Unlisted
    • Not otherwise classified (NOC)
    • Unspecified
    • Unclassified
    • Other
    • Miscellaneous
  2. When billing for specific supplies and materials, avoid using CPT code 99070 (General Supplies) and you should be as specific as possible. The only time the general supplies code should be used is when a Medicare administrative contractor or local payer directs you to do this.
  3. Coding and billing should always be based on the service provided. Documentation should also be provided detailing the patient’s problem and the services provided in order for the payer to determine reasonableness and necessity of care.
  4. Always refer to the Online CMS Manual System or a third-party payment policy in order to determine whether the care provided is a covered service.
  5. If you come across a circumstance where a CPT and HCPCS Level II code share nearly identical narratives, apply the CPT code. When the narratives are not identical, select the code that best describes the service. For Medicare claims, you will usually find the HCPCS Level II codes more specific and will generally take precedence over the CPT code.

HCPCS Level II codes consist of one alphabetic character (letters A through V) and four numbers (listed below). 

  • A-codes: A0021 – A999
    • Transportation, Medical and Surgical Supplies, Miscellaneous and Experimental
  • B-codes: B4034 – B999
    • Enteral and Parenteral Therapy
  • C-codes: C1713 – C9899
    • Outpatient Prospective Payment System (PSS)
  • E-codes: E0100 – E8002
    • Durable Medical Equipment
  • G-codes: G0008 – G9977
    • Temporary Procedures and Professional Services
  • H-codes: H0001 – H2037
    • Rehabilitative Services
  • J-codes: J0120 – J9999
    • Drugs administered other than oral method, chemotherapy drugs
  • K-codes: K0001 – K0900
    • Temporary codes for durable medical equipment for Medicare Administrative Contractors
  • L-codes: L0112 – L9900
    • Orthotic/prosthetic services
  • M-codes: M0075 – M0301
    • Medical services
  • P-codes: P2028 – P9615
    • Pathology and Laboratory
  • Q-codes: Q0035 – Q9989
    • Temporary Miscellaneous services
  • R-codes: R0070 – R0076
    • Diagnostic radiology services
  • S-codes: S0012 – S9999
    • Private payer codes
  • T-codes: T1000 – T5999
    • State Medicaid agency codes
  • V-codes: V2020 – V5364
    • Vision/hearing and speech-language pathology services

HCPCS Level II codes can also have modifiers, which can be alphanumeric or two letters.  The three most common HCPCS Level II modifiers are:

  1. GP Modifier. The GP modifier indicates that a service has been delivered under an outpatient physical therapy plan of care.
  2. KX Modifier. The KX modifier indicates that all medical policy and documentation requirements have been met and that the billed item is reasonable and necessary. This modifier is added to each procedure code once the specific therapy cap has been met.
  3. GA Modifier. The GA modifier is added to claims with a properly executed Advanced Beneficiary Notice (ABN) in the file for a service not considered medically necessary. The GA Modifier is added when the KX Modifier cannot be added.

A key component in accurate reimbursement is a thorough understanding of the multiple coding systems that are used to identify services and supplies.  Unfortunately, the coding systems can be complicated and sometimes downright confusing. StrataPT offers practical systems and business solutions, along with an unparalleled level of support to ensure that your billing process is accurate and always up to date.  To learn more, please contact us to learn how we can make a difference in your practice.

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