MCRW Ch 3

developed and maintained by CMS (Medicare billing) yearly updates
- supplies, services, or other treatments, including ambulance

Level 2 (HCPCS)

Current Procedural Terminology
Maintained (and copyrighted) by the AMA, updated yearly
- procedure, treatments, and services provided

Level 1 (CPT)

HCPCS

CPT

CPT

5 digit codes, never more, never less
may have modifiers appended (with a dash and 2 characters -50)
There are inpatient E/M codes but the remainder are for outpatient procedures/non-facility
Each code has a dollar amount tied to it to include risk, overhead, skill, and amount of work required
MUST be billed with a CM code to indicate medical necessity

provides additional info or modifies the code description

Full list of descriptions are in the Appendix in the back (LABEL IT)
Quick/common list found on the front flap
Some HCPCS modifiers are included to (digits)
Some are informational and some impact payment - so be careful!

Lets look at some examples:

-50
-52
-51
-22

Impact Payment

-RT
-LT
-32
-33
-TA, -T4 etc
-LC

Informational

5 Digits- ALWAYS start with a letter

Commonly used in conjunction with CPT to identify additional supplies/services/drugs
Example: Patient comes for Flu Vaccine - both get reported. Why?
Not required for every claim
Still require medical necessity
MCR will reject CPT codes if a HCPCS codes exists for it (ex: CA Screen)
HCPCS modifiers may be appended

Updates

ICD-10 codes and books are implemented on October 1 of every year (ICD-10-CM and PCS 2024 codes are now being used)

CPT codes/books are implemented January 1 of every year (Still using 2023 CPT)

HCPCS codes are updated QUARTERLY, but the books only updated yearly with CPT (Jan 1) - must use CMS website to check for quarterly updates

Inpatient
Must have at least one CM codes, may or may not have a procedure code

UB-04 - see pg 32

Outpatient procedures/services
Must have 1 of each CM and CPT or HCPCS

CMS-1500- see pg 31

Other code uses

-risk adjustment
- performance measures
- public health tracking
-Internal tracking
- quality improvement
-Research and Funding
-Facility utilization evaluation

Released in 2018 but...

It took 20 years for the US to let go if ICD-9 and transition to ICD-10
It was a big, drawn out ordeal
ICD-11 is available and out there, but we may not be seeing it any time soon.
Just remember, you would not be learning a whole new code set the way you are learning it now, you would simply be finding different results and seeing new guidelines

The DX must match the procedure

Especially important when multiple procedures and dx's exist.
Read the example at the bottom of 80
E/M > swimmers ear
Cryosurgery > wart
What might happen if these are not linked properly?
Could E/M be denied?

​Document it

​Documentation must be...

-complete
-detailed
- legible
-contain necessary identifiers
-(formatted)

What if guidelines and insurance clash?

Compliance is key!

Follow guidelines as closely as possible
Be ETHICAL