HCPCS Level II for Payers

Transcription

1 HCPCS Level II for Payers 2006

2 Introduction Organization of HCPCS The Ingenix 2006 HCPCS Level II book contains mandated changes and new codes for use as of January 1, eleted codes have also been indicated and cross-referenced to active codes when possible. New codes have been added to the appropriate sections, eliminating the time-consuming step of looking in two places for a code. However, keep in mind that the information in this book is a reproduction of the 2006 HCPCS; additional information on coverage issues may have been provided to Medicare contractors after publication. All contractors periodically update their systems and records throughout the year. If this book does not agree with your contractor, it is either because of a mid-year update or correction, or a specific local or regional coverage policy. To make this year s HCPCS book even more useful, we have included codes noted in addendum B of the November 2005 OPPS update as published in the Federal Register and from transmittals through 2005 that include codes not discussed in other CMS documents. The sources for these codes are often noted in blue beneath the description. individual ranges of codes. Just look up the medical or surgical supply, service, orthotic, prosthetic, or generic or brand name drug in question to find the appropriate codes. This index also refers to many of the brand names by which these items are known. Table of rugs The brand names listed are examples only and may not include all products available for that type of drug. Our table of drugs lists HCPCS codes from any available sections including A codes, C codes, J codes, S codes, and Q codes under brand and generic drug names with amount, route of administration, and code numbers. While we try to make the table comprehensive, it is not all-inclusive. Color-coded Coverage Instructions The Ingenix HCPCS Level II codebook provides colored symbols for each coverage and reimbursement instruction. A legend to these symbols is provided on the bottom of each two-page spread. Index Since HCPCS is organized by code number rather than by service or supply name, the index enables the coder to locate any code without looking through How to Use Ingenix HCPCS Level II Books Blue Color Bar Special Coverage Instructions A blue bar for special coverage instructions over a code means that special coverage instructions apply to that code. These special instructions are also typically given in the form of Medicare Pub.100 reference numbers. The appendixes provide the full text of the cited Medicare Pub.100 references. Yellow Color Bar Carrier iscretion Issues that are left to contractor discretion are covered with a yellow bar. Contact the contractor for specific coverage information on those codes. <b>a4211 <o>a4248 Supplies for self-administered injections Chlorhexidine containing antiseptic, 1 ml Red Color Bar Not Covered by or Invalid for Medicare Codes that are not covered by or are invalid for Medicare are covered by a red bar. The pertinent Medicare Internet-only manuals (pub. 100) reference numbers are also given explaining why a particular code is not covered. These numbers refer to the appendixes, where we have listed the Medicare references. <o>a4223 Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) The Ingenix HCPCS Level II codes follow the AMA CPT code book conventions to indicate new, revised, and deleted codes. A black circle (l) precedes a new code. A black triangle (s) precedes a code with revised terminology or rules. A circle (l) precedes a reinstated code. Codes deleted from the 2005 active codes appear with a strike-out. Quantity Alert Many codes in HCPCS report quantities that may not coincide with quantities available in the marketplace. For instance, a HCPCS code for an ostomy pouch with skin barrier reports each pouch, but the product is generally sold in a package of 10; 10 must be indicated in the quantity box on the CMS claim form to ensure proper reimbursement. This symbol indicates that care should be taken to verify quantities in this code. l A4411 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, with built-in convexity, each s A4641 Radiopharmaceutical, diagnostic, not otherwise classified l J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, non-compounded A4260 Levonorgestrel (contraceptive) implants system, including implants and supplies See code(s) J A4207 Syringe with needle, sterile 2 cc, each 2006 HCPCS Introduction iii

3 w Female Only This icon identifies procedures that should only be reported for female patients. m Male Only This icon identifies procedures that should only be reported for male patients. A4280 A4326 Adhesive skin support attachment for use with external breast prosthesis, each Male external catheter specialty type with integral collection chamber, each m w v Age Edit This icon denotes codes intended for use with a specific age group, such as neonate, newborn, pediatric, and adult. Carefully review the code description to assure the code you report most appropriately reflects the patient s age Limited orthodontic treatment of the primary dentition v w Maternity This icon identifies procedures that by definition should only be used for maternity patients generally between 12 and 55 years of age. H1001 Prenatal care, at-risk enhanced service; antepartum management w 1-9 ASC Groupings Codes designated as being paid by ASC groupings that were effective at the time of printing are denoted by the group number. MEPOS Use this icon to identify when to consult the CMS MEPOS for payment of this durable medical item. G0105 Colorectal cancer screening; colonoscopy on individual at high risk 2 A4322 Irrigation syringe, bulb or piston, each Skilled Nursing Facility (SNF) Use this icon to identify certain items and services not covered under the Skilled Nursing Facility Prospective Payment System (SNFPPS). A0999 Unlisted ambulance service * Ingenix provides explanatory information in blue beneath many codes. These annotations help you better understand the code and its billing. J7191 Factor VIII (anti-hemophilic factor (porcine), per IU Use this code for Hyate:C. Medicare jurisdiction: local contractor. rugs commonly reported with a code are listed underneath by brand or generic name. J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per IU Use this code for AlphaNine S, Mononine. See references help you determine related or alternate codes for the supply or service. J7502 Cyclosporine, oral, 100 mg Use this code for Neoral, Sandimmune, Gengraf, Sangcya. See also code: C9438 CMS does not use consistent terminology when a code for a specific procedure is not listed. The code description may include any of the following terms: unlisted, not otherwise classified (NOC), unspecified, unclassified, other, and miscellaneous. If you are sure there is no code for the service or supply provided or used, be sure to provide adequate documentation to the payer. Check with the payer for more information. A0999 Unlisted ambulance service iv Introduction 2006 HCPCS

4 APC Status Indicators A-Y APC Status Indicators Status indicators identify how individual HCPCS Level II codes are paid or not paid under the OPPS. The same status indicator is assigned to all the codes within an APC. Consult the payer or resource to learn which CPT codes fall within various APCs. Status indicators for HCPCS and their definitions are below: A Indicates services that are paid under some other method such as the MEPOS fee schedule or the physician fee schedule B Indicates codes not allowed or paid under OPPS C Indicates inpatient services that are not paid under the OPPS E Indicates services for which payment is not allowed under the OPPS. In some instances, the service is not covered by Medicare. In other instances, Medicare does not use the code in question but does use another code to describe the service F Indicates corneal tissue acquisition costs, certain CRNA services and hepatitis B vaccines that are paid at reasonable cost G Indicates a current drug or biological for which payment is made under the transitional pass-through provisions H Indicates either a device paid under pass-through provisions; or brachytherapy sources and radiopharmaceuticals that are paid at reasonable cost K Indicates non-pass-through drugs and biologicals. Effective July 1, 2001, co-payments for these items and the service of the administration of the items are aggregated and may not exceed the inpatient hospital deductible. L Indicates influenza or pneumococcal pneumonia vaccine paid as of reasonable cost with no deductable or coinsurance M Indicates that this code should not be reported by hospitals to their fiscal intermediary N Indicates services that are incidental, with payment packaged into another service or APC group P Indicates services paid only in partial hospitalization programs S Indicates significant procedures for which payment is allowed under the hospital OPPS but to which the multiple procedure reduction does not apply T Indicates surgical services for which payment is allowed under the hospital OPPS. Services with this payment indicator are the only ones to which the multiple procedure payment reduction applies. V Indicates visits for which payment is allowed under the hospital OPPS X Indicates ancillary services for which payment is allowed under the hospital OPPS Y Indicates nonimplantable durable medical equipment (ME) that is billed by providers other than home health agencies to the MERC The Q icon is not included because there are no codes that have a Q status indicator in the 2006 HCPCS Level II code set. A A4321 Therapeutic agent for urinary catheter irrigation B A4550 Surgical trays C G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion E A0021 Ambulance service, outside state per mile, transport (Medicaid only) F V2785 Processing, preserving and transporting corneal tissue G C9113 Injection, pantoprazole sodium, per vial H A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie K A9535 Injection, methylene blue, 1 ml L G0008 Administration of influenza virus vaccine when no physician fee schedule service on the same day M G0333 ispense fee initial 30 day N A4220 Refill kit for implantable infusion pump P G0177 Training and educational services related to the care and treatment of patient s disabling mental health problems per session (45 minutes or more) S C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval T C9724 Endoscopic full-thickness plication in the gastric cardia using endoscopic plication system (EPS); includes endoscopy V G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination X C8952 Therapeutic, prophylactic or diagnostic injection; intravenous push Y A4222 Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) ME: This notation precedes an instruction pertaining to this code in the Centers for Medicare and Medicaid Services (CMS) Publication 100 (Pub 100) electronic manual or in a National Coverage eterminatuion (NC). These CMS sources, formerly called the Medicare Carriers Manual (MCM) and Coverage Issues Manual (CIM), present the rules for submitting these services to the federal government or its contractors and are included in the appendix of this book AHA: American Hospital Association Coding Clinic for HCPCS citations help you find expanded information about specific codes and their usage. A4300 A4290 Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access ME: 100-2, 15, 120 Sacral nerve stimulation test lead, each AHA: 1Q, 02, 9 Current as of 11/23/2005 You may subscribe to an service to receive special reports when information in this book changes. Contact Customer Services at INGENIX, option HCPCS Introduction v

5 Tabular List MEICAL AN SURGICAL SUPPLIES A6453 A 4 [o]a6252 Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing A 4 [o]a6253 Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing A 4 [o]a6254 Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing A 4 [o]a6255 Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing A 4 [o]a6256 Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing A 4 [o]a6257 Transparent film, 16 sq. in. or less, each dressing Use this code for Polyskin, Tegaderm, and Tegaderm HP. A 4 [o]a6258 Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing A 4 [o]a6259 Transparent film, more than 48 sq. in., each dressing A [o]a6260 Wound cleansers, any type, any size * A 4 [o]a6261 Wound filler, gel/paste, per fluid oz., not elsewhere classified A 4 [o]a6262 Wound filler, dry form, per gram, not elsewhere classified A 4 [o]a6266 Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard A 4 [o]a6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing A 4 [o]a6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing A 4 [o]a6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 4 [y]a6407 Packing strips, non-impregnated, up to two in. in width, per linear yard A 4 [o]a6410 Eye pad, sterile, each A 4 [o]a6411 Eye pad, non-sterile, each E 4 [o]a6412 Eye patch, occlusive, each A 4 [y]a6441 Padding bandage, non-elastic, non-woven/ nonknitted, width greater than or equal to 3 in. and less than 5 in., A 4 [y]a6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than 3 in., A 4 [y]a6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 3 in. and less than 5 in., A 4 [y]a6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 in., A 4 [y]a6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than 3 in., A 4 [y]a6446 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 3 in. and less than 5 in., A 4 [y]a6447 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 5 in., A 4 [y]a6448 Light compression bandage, elastic, knitted/woven, width less than 3 in., A 4 [y]a6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in., A 4 [y]a6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 in., A 4 [y]a6451 Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50 percent maximum stretch, width greater than or equal to 3 in. and less than 5 in., A 4 [y]a6452 High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 percent maximum stretch, width greater than or equal to 3 in. and less than five in., A 4 [y]a6453 Self-adherent bandage, elastic, non-knitted/nonwoven, width less than 3 in., Medical and Surgical Supplies A6252 A6453 Special Coverage Instructions Noncovered by Medicare Carrier iscretion 4 Quantity Alert l New Code l Reinstated Code s Revised Code 2006 HCPCS 1-9 ASC Groups ME: Pub 100/NC Reference MEPOS Paid * SNF Excluded A Codes 13

6 Tabular List ORTHOTIC PROCEURES AN EVICES L3251 B 4 [o]l3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, B 4 [o]l3030 Foot insert, removable, formed to patient foot, E 4 [y]l3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, ARCH SUPPORT, REMOVABLE, PREMOLE B 4 [o]l3040 Foot, arch support, removable, premolded, longitudinal, B 4 [o]l3050 Foot, arch support, removable, premolded, metatarsal, B 4 [o]l3060 Foot, arch support, removable, premolded, longitudinal/metatarsal, ARCH SUPPORT, NONREMOVABLE, ATTACHE TO SHOE B 4 [o]l3070 Foot, arch support, nonremovable, attached to shoe, longitudinal, B 4 [o]l3080 Foot, arch support, nonremovable, attached to shoe, metatarsal, B 4 [o]l3090 Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, B [o]l3100 Hallus-valgus night dynamic splint * ABUCTION AN ROTATION BARS B [o]l3140 Foot, abduction rotation bar, including shoes * B [o]l3150 Foot, abduction rotation bar, without shoes * B [y]l3160 Foot, adjustable shoe-styled positioning device * s A [o]l3170 Foot, plastic, silicone or equal, heel stabilizer, ORTHOPEIC FOOTWEAR B [o]l3201 Orthopedic shoe, Oxford with supinator or pronator, infant v* B [o]l3202 Orthopedic shoe, Oxford with supinator or pronator, child v* B [o]l3203 Orthopedic shoe, Oxford with supinator or pronator, junior v* B [o]l3204 Orthopedic shoe, hightop with supinator or pronator, infant v* B [o]l3206 Orthopedic shoe, hightop with supinator or pronator, child v* B [o]l3207 Orthopedic shoe, hightop with supinator or pronator, junior v* B 4 [o]l3208 Surgical boot, each, infant v* B 4 [o]l3209 Surgical boot, each, child v* B 4 [o]l3211 Surgical boot, each, junior v* B 4 [o]l3212 Benesch boot, pair, infant v* B 4 [o]l3213 Benesch boot, pair, child v* B 4 [o]l3214 Benesch boot, pair, junior v* s A [o]l3215 Orthopedic footwear, ladies shoe, oxford, each vw* s A [o]l3216 Orthopedic footwear, ladies shoe, depth inlay, each vw* s A [o]l3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each vw* s A [o]l3219 Orthopedic footwear, mens shoe, oxford, each s A [o]l3221 Orthopedic footwear, mens shoe, depth inlay, each vm* vm* s A [o]l3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each vm* A [o]l3224 Orthopedic footwear, woman s shoe, Oxford, used as an integral part of a brace (orthosis) w Orthotic Procedures and evices L3020 L3251 A enis-browne style splint is a bar that can be applied by strapping or mounted on a shoe. This type of splint generally corrects congenital conditions such as genu varus enis-browne splint The angle may be adjusted on a plate on the sole of the shoe A [o]l3225 Orthopedic footwear, man s shoe, Oxford, used as an integral part of a brace (orthosis) m s A [o]l3230 Orthopedic footwear, custom shoe, depth inlay, B 4 [o]l3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, B 4 [o]l3251 Foot, shoe molded to patient model, silicone shoe, Special Coverage Instructions Noncovered by Medicare Carrier iscretion 4 Quantity Alert l New Code l Reinstated Code s Revised Code 2006 HCPCS 1-9 ASC Groups ME: Pub 100/NC Reference MEPOS Paid * SNF Excluded L Codes 103