Coding 101: What are HCPCS codes?

 

The term HCPCS codes is ubiquitous in the medical claim billing universe and spans services provided in the treatment of patients to drug billing by pharmacies. The acronym HCPCS (usually pronounced “hick-pick”) stands for Healthcare Common Procedure Coding System and it is comprised of two separate code systems. The first coding system is known as Current Procedural Terminology (CPT®) or Level I HCPCS codes. These codes are maintained by the American Medical Association (AMA) and serve as the coding system by which physicians bill for the various services and procedures that they render. CPT® codes, in general, do not provide a coding system for specific products used during a procedure, therefore that is why CMS created a second code set known as Level II HCPCS codes, which are the codes that RJ Health has specialized in since 1999. The level II codes are utilized for drugs, supplies, durable medical equipment, and for filling in gaps within the CPT coding system. There is a universal need for accurate HCPCS data across the whole spectrum of medical care provision including: Payors, Physicians, Manufacturers, and Providers.

The Level II HCPCS coding structure starts with a letter and are followed by 4 digits. The specific letter that a code starts with is specific to the type of product that is coded to the code. The following chart shows the various code types:

Level II HCPCS Code Type
What does it include?
Example
   A-Codes*
Transportation, Medical & Surgical Supplies, Diagnostic and Therapeutic Radiopharmaceuticals
A9556 – Gallium Ga-67 citrate, diagnostic, per millicurie
    B-Codes*
Enteral and Parenteral Therapy
B4103 – Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 mL = 1 unit
    C-Codes**
Temporary Hospital Outpatient Prospective Payment System
C9473 – Injection, mepolizumab, 1 mg
    E-Codes*
Durable Medical Equipment
E0607 – Home blood glucose monitor
    G-Codes*
Temporary Procedures & Professional Services
G0008 – Administration of influenza virus vaccine
    H-Codes***
Rehabilitative Services
H0001 – Alcohol and/or drug assessment
    J-Codes**
Drugs, biologicals, and chemotherapy
J1745 – Injection infliximab, 10 mg
    K-Codes***
Temporary Codes for Durable Medical Equipment Regional Carriers
K0001 – Standard wheelchair
    L-Codes***
Orthotic/Prosthetic Procedures
L0140 – Cervical, semi-rigid, adjustable (plastic collar)
    M-Codes***
Medical Services
M0075 – Cellular therapy
    P-Codes*
Pathology/Laboratory Services and various Blood Products
P9041 – Infusion, albumin (human), 5%, 50 mL
    Q-Codes*
Temporary Codes
Q0144 – Azithromycin dihydrate, oral, capsules/powder, 1 gram
    R-Codes***
Diagnostic Radiology Services
R0076 – Transportation of portable EKG to facility or location, per patient
    S-Codes*
Private Payer Codes (Non-Medicare)
S0073 – Injection, aztreonam, 500 mg
    T-Codes***
State Medicaid Agency Codes
T1016 – Case management, each 15 minutes
    V-Codes***
Vision/Hearing Services
V2121 Lenticular lens, per lens, single
*= Some codes, but not all, can be found on the current ReimbursementCodes website
**= All codes can be found on the current ReimbursementCodes website
***= No codes can be found on the current ReimbursementCodes website

 

In our consulting with payors of various sizes we have found that these codes can equate to a $15 to $25 PMPM spend. And well over 50% of the billings from Specialist Practice areas are drug products.  So, the reliability and accuracy of the code assignments and associated pricing for Specialty drugs has significant cost implications to all involved. At RJ Health, our expertise in the coding of drugs has led to the establishment of industry standard data and the development of productivity and analysis tools that assist our various types of clients with Medical Pharmacy trend management. As the industry’s most authoritative and trusted medical drug information source, we maintain comprehensive pricing and clinical data within our various databases, website solutions, and automated medical edits. Through the use of our data and tools our customers realize increases in claim accuracy and pricing, which results in savings and improved revenue.To see how our various tools can help your organization achieve an end-to-end solution that reduces medical drug errors, reduces costs, and improves revenue please contact info@rjhealth.com for a demonstration.