(Medicare Claims Processing Manual)

Both the DME MACs and the A/B MACs (B) publish this list to educate providers on which MAC they should bill for codes provided on this list.   Physicians and suppliers must use HCPCS codes on the Form CMS -1500 or its electronic equivalent and providers must use HCPCS codes on the Form CMS -1450 or its electronic equivalent for most outpatient services.  The procedure, item, or service can be further described by using 2- position modifiers contained in HCPCS.   Modifiers to HCPCS Level I codes for medicine, anesthesia, surgery, radiology, and pathology are on the HCPCS codes file from CMS.  Modifiers for Level II alpha -numeric codes are with the Level II codes published by CMS.  Alpha -numeric and CPT -4 modifiers may be used with either alpha -numeric or CPT -4 codes.  A/B MACs (A, B and HHH) and DME MACs are required to accept up to four 2 -position numeric or alpha modifiers and process both modifiers completely through the claims processing system (including any manual portion) as far as payment history.  It is not acceptable merely to be able to accept multiple modifiers and then drop one before complete systems processing.  Dropping of a modifier leads to incomplete and inaccurate pricing profiles.   Series Q, K, and G in the Level II coding are reserved for CMS assignment.  Q, K, and G codes are temporary  national codes for items or services requiring uniform national coding between one years update and the next.  Sometimes temporary codes remain for more than one update.  If Q, K, or G codes are not converted to permanent codes in the Level I or Level II series in the following update, they will remain active until converted or until CMS notifies MACs to delete them.  All active  Q, K, and G codes at the time of update will be included on the update file for MACs.  In addition, deleted codes are retained on the file for informational purposes, with a deleted indicator, for four years.   Series S Level II codes are reserved for use by the BCBSA and other private insurers.  These codes provide for reporting needs unique to those organizations.  Each State defines its own Medicaid coverage, payment, and utilization levels.  The CMS does not impose Medicare requirements on Medicaid programs.  The HCPCS simply provides a system for identifying services that can be expanded to meet everyones needs.   20.4 - Deleted HCPCS Codes/Modifiers  (Rev. 10320, Issued: 08- 28-2020, Effective: 12 -01-2020, Implementation: 12- 01-2020)   Claims for services in a prior year are reported and processed using the HCPCS codes/modifiers in effect during that year.  For example, a claim for a service furnished in November 2019 but received by an A/B MAC (A), (B), or (HHH), or DME MAC in 2020, should contain codes/modifiers valid in 2019 and is processed using the prior years pricing files.   HCPCS codes (Level I CPT -4 and Level II alpha -numeric) are updated on a quarterly basis.  Each quarter (January, April, July and October), CMS releases the HCPCS file to A/B MACs (A), (B), (HHH), and DME MACs.  The HCPCS file contains the CPT -4 and the alpha-numeric updates.  All MACs are notified of the release date via a one- time notification instruction.  The file contains new, deleted, and revised HCPCS codes which are effective for the upcoming quarter.   The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be date of service compliant.    Providers can purchase the American Medical Associations CPT -4 coding book that is published each October that contains new, revised, and discontinued CPT -4 codes for the upcoming year.  In addition, CMS posts on its Web site the alpha -numeric HCPCS file.   Providers are encouraged to access CMS web site to see the new, revised, and discontinued alpha -numeric codes.  The CMS web site to view the HCPCS update is https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha -Numeric -HCPCS.html .  A/B MACs (B) and DME MACs must reject services submitted with discontinued HCPCS codes.  A/B MACs (A) and (HHH) must return to the provider (RTP) claims containing deleted codes.   See the Medicare Claims Processing Manual, Chapter 22, Remittance Notices to Providers.   20.5 - The HCPCS Codes Training (Rev. 1, 10- 01-03) HO- 442.5  A large number of changes to HCPCS codes may necessitate the training of physician, supplier and provider personnel.  If this is necessary, MACs must schedule the sessions in conjunction with the State medical records association or the State hospital or medical/physician associations.  All MACs should schedule sessions in the major population centers of their service area.   All MACs should use the following guidelines in planning training sessions.   Limit the training sessions to a manageable size to encourage questions and answers.   A/B MACs (B) should limit sessions to office staffs of homogenous medical specialties, e.g., do not include DME suppliers with staff from physicians offices.    Invite office personnel who complete bills and claims to attend.    In conducting the training, emphasize the use of the new HCPCS/CPT -4 manuals and the proper completion of the claim forms using the new codes.   Be alert to a specific physician/supplier/provider having difficulty with HCPCS.  Provide follow up training focused to the individual situation.  Review and discuss specific billing problems over the phone or by mail.  If many problems develop with a spec ific provider, the MAC schedules a visit to provide the specific training needed.  Training is the A/B MACs (A)s, (B)s, (HHH)s, and DME MACs responsibility.   20.6 - Professional/Public Relations for HCPCS  (Rev. 1, 10- 01-03)  A/B MACs (A), (B), (HHH), and DME MACs must perform the following professional/public relations activities:  Designate a knowledgeable person as a focal point for physician, supplier and provider inquiries.  This person must be able to address coding and payment questions.   Notify physicians, suppliers and providers by newsletter and Web site at least 30 days before codes are changed, added or deleted.  Also, notify them when general problems arise including coding issues.   A/B MACs (B) should share Level III codes/modifiers with the Medicaid State agency in the A/B MAC (B)s jurisdiction.   Advise physicians and providers to obtain new copies of CPT -4 annually from the AMA.  Orders can be placed by calling 1- 800-621-8335 or order online at www.ama -assn.org/catalog   A/B MACs (A) and (HHH) supply providers with CMS alpha -numeric code updates and with any local codes.  See 20 for sources.  A/B MACs (B) supply the current HCPCS local codes/modifiers (alpha -numeric W -Z) since they are the only source.    A/B MACs (A), (B), (HHH), and DME MACs inform physicians, suppliers, and providers when the annually and quarterly updated HCPCS codes become available and effective in the claims processing system.    All codes/modifiers contained in the current version of the HCPCS will be recognized and processed unless they have been deleted or are indicated as not valid for Medicare.    It is important for physicians, practitioners, suppliers, and providers to note that code/modifier recognition does not imply that a service is covered by Medicare.  In addition, a separate code does not mean that the payment level will be different from similar services identified by different codes.    Since local changes can occur throughout the year, continue professional relations activities to provide as much information as possible to providers.   20.7 - Use of the American Medical Associations (AMAs) Physicians Current Procedural Terminology (CPT) Fourth Edition Codes, and Use of the American Dental Associations (ADAs) Current Dental Terminology-Fourth Edition (CDT) Codes, on A/B MACs (A)s, (B)s, (HHH)s, and DME MACs  Web Sites and Other Electronic Media  (Rev. 10211, Issued: 07- 10-2020, Effective: 08 -10-2020, Implementation: 08- 10-2020)   See Business Requirements at http://www.cms.hhs.gov/manuals/pm_trans/R43CP.pdf  CMS AMA- ADA-AHA Medical Codes Overview  The Centers for Medicare & Medicaid Services (CMS) staff may access the following copyright protected medical codes and descriptors:   American Medical Associations Current Procedural Terminology  AMA/CPT   American Dental Associations Current Dental Terminology  ADA/CDT   American Hospital Associations National Uniform Billing Codes  AHA/NUBC UB-04   CMS signed licensing agreements with the AMA, ADA, and AHA giving staff limited use of CPT, CDT, and NUBC data codes and descriptors.   Access the CPT, CDT, or NUBC codes  Prior to accessing the codes, CMS staff must accept the terms and conditions of an association's licensing agreement.   American Medical Associations Current Procedural Terminology  AMA/CPT  o     AMA Terms and Conditions  o    AMA CPT Exhibits Directory   American Dental Associations Current Dental Terminology  ADA/CDT  o     ADA Terms and Conditions  o     ADA CDT Exhibits Directory   American Hospital Associations National Uniform Billing Codes  AHA/NUBC  o     AHA Terms and Conditions  o    AHA NUBC Exhibits Directory    Any proposed usage not covered by the current agreement requires the completion of a CPT-CDT -NUBC New Use Application . CMS, then, will negotiate your new use with the appropriate association.   20.8 - Payment, Utilization Review (UR), and Coverage Information on CMS Annual HCPCS Codes Update File  (Rev. 10320, Issued: 08- 28-2020, Effective: 12 -01-2020, Implementation: 12- 01-2020)   The file CMS provides for the quarterly update of HCPCS codes contains fields for payment, UR, and coverage information to assist in developing front -end edit screens.  Coverage information is not all inclusive, but should be used mainly as a guide in establishing specific review limits.  A/B MACs (B) must establish reasonable developmental guidelines, review screens, and relative value units, as appropriate.  A/B MACs (B) must assure that their system processes claims in accordance with CMS policies and pr ocedures, including changes that may occur between HCPCS codes updates.    Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as Level II codes/modifiers prefixed with Q or K or G.  Questions may arise in updating that require A/B MAC (B) staff to refer to a physicians or suppliers pricing history.  Therefore, keep an electronic backup of HCPCS codes for the two prior years with linkages to pricing profiles.  Perform required computer analysis as necessary.   The HCPCS terminology seldom includes a place of service designation.  Where place of service affects pricing, pricing is obtained from the place of service field on the claim record.   A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage policies from CMS.  A/B MACs (A) and (HHH) must assure that system claims processing complies with CMS policy and procedures.   20.9 - National  Correct Coding Initiative (NCCI)                                    (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)