Correct Healthcare Common Procedure Coding System (HCPCS) code selection is an essential element for claims payment. Choosing correct HCPCS code is an essential for accurate insurance reimbursements. On the other hand, incorrect coding may result in improper payment necessitating recoupment and possible false claim actions.

1. Basics Of Choosing Correct HCPCS Code

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Basics Of Choosing Correct HCPCS Code
Correct Healthcare Common Procedure Coding System (HCPCS) code selection is an essential element for claims
payment. Choosing correct HCPCS code is an essential for accurate insurance reimbursements. On the other hand,
incorrect coding may result in improper payment necessitating recoupment and possible false claim actions. It is
important that all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers take steps to
ensure that claims are correctly coded. Each payer separately develops their own coverage criteria, coding guidelines,
and fees for HCPCS Level II codes.
Background of HCPCS Code
The HCPCS is a standardized set of codes used for billing items and services to all payers, including Medicare and
Medicaid. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS.
• The HCPCS is divided into two principal subsystems, referred to as level I and level II. Level I of the HCPCS is
comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical
Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are
used primarily to identify medical services, dental services, and procedures furnished by physicians and other
healthcare professionals.

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Email us at: richard.smith@medisysdata.com
Basics Of Choosing Correct HCPCS Code
• Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4), a numeric coding system maintained by
the American Medical Association (AMA). The CPT-4 is a uniform coding system consisting of descriptive terms and
identifying codes that are used primarily to identify medical services and procedures furnished by physicians and
other healthcare professionals. These healthcare professionals use the CPT-4 to identify services and procedures for
which they bill public or private health insurance programs. Level I of the HCPCS, the CPT-4 codes, does not include
codes needed to separately report medical items or services that are regularly billed by suppliers other than
physicians.
• Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services
not included in the CPT codes, such as ambulance services and DMEPOS when used outside a physician’s office.
Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by
CPT codes, the level II HCPCS codes were established for submitting claims for these items.
Choosing the Correct HCPCS Code
Each supplier is responsible for the HCPCS code(s) they select to bill for the items provided. Here are some tips that will
help:
• Always refer to the ‘long’ code narrative. All codes have short and long descriptors. The long descriptor often
provides more detail regarding the requirements for the code. Select the code with the descriptor that most closely
describes the product.

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Basics Of Choosing Correct HCPCS Code
• Suppliers should check with the pricing, coding analysis, and coding (PDAC), contractor to CMS. The PDAC is
responsible for providing suppliers and manufacturers with assistance in determining which HCPCS code should be
used to describe DMEPOS items for the purpose of billing Medicare.
• You can check Medicare Administrative Contractor (MAC) publications for coding bulletins and coding guidelines
related to products and HCPCS codes for specific information on the item of interest.
• Most code narratives are written broadly to be all-inclusive. You may not find a specific code that perfectly matches a
product. Use the code that most closely describes the item rather than a NOC (not otherwise classified) or
miscellaneous code.
• Local Coverage Determination (LCD) related policy articles often have additional information in the coding guidelines
section. Coding guidelines provide additional information on the characteristics of products that meet a specific
HCPCS code.
• Note that the price and fees are not part of the correct coding. Selecting a code based upon the fee schedule may
result in an incorrect coding determination. HCPCS codes describe the product, not the price.
• Correct coding is an essential element for correct claim payment. The insurance carrier maintains a variety of
resources to assist suppliers in determining the appropriate code.
Medisys Data Solutions is a leading medical billing company providing complete billing and coding services for various
medical billing specialties. We shared basic information on choosing correct HCPCS code for provider reference
purposes. For a detailed understanding, you can check the following reference links. If you are seeking assistance in
coding for your practice, contact us at info@medisysdata.com / 888-720-8884

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