Glossary / HCPCS
HCPCS Healthcare Common Procedure Coding SystemHCPCS (Healthcare Common Procedure Coding System)
The code set every DMEPOS claim is billed under; Level II codes are a letter plus four digits, such as E0601 for CPAP or E1390 for an oxygen concentrator.
The Healthcare Common Procedure Coding System (HCPCS) has two levels. Level I is CPT, the numeric procedure codes maintained by the American Medical Association. Level II is maintained by CMS and identifies products, supplies, and services that CPT does not cover, including durable medical equipment, prosthetics, orthotics, supplies, drugs, and ambulance services. A Level II code is a single letter followed by four digits.
In DME the HCPCS code is the unit of everything: the fee schedule amount, the LCD that governs coverage, whether the item is on the Required Prior Authorization List or the face-to-face list, and how it is paid. E0601 is a CPAP device, E1390 a stationary oxygen concentrator, E0470 a bi-level respiratory assist device, E0260 a semi-electric hospital bed, and the K-codes cover power mobility devices.
CMS updates Level II codes on a quarterly cycle for drugs and biologicals and twice a year for other items, so a code that was correct last year may have been split, replaced, or retired. Check the current HCPCS file before declaring a code on a case.
Common questions
Where do I look up whether a code needs prior authorization?
CMS's Required Prior Authorization List, published with the Master List, is organized by HCPCS code. Items are added with at least 60 days' notice, so check the current version.
Why does a case start with a HCPCS code?
Because the code selects the rules. The LCD, the policy article, the PA and face-to-face lists, and the fee schedule all key off it; AffirmDME builds the readiness checklist from the code declared on the case.
Related
See the term in a real checklist.
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Sources: CMS: Healthcare Common Procedure Coding System (HCPCS) · CMS: Master List and Required Lists . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- Affirmation and non-affirmation
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- NCD — National Coverage Determination
- Policy article
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review