Question

create a two-paragraph scenario where HCPCS Level I and Level II are used
together.

Answer 1

This code set is based upon CPT. In fact, the first level of HCPCS is identical to CPT. That might sound a little confusing, so let’s take a step back.

HCPCS was developed by the Centers for Medicare and Medicaid (CMS) for the same reasons that the AMA developed CPT: for reporting medical procedures and services. Up until 1996, using HCPCS was optional. In that year, however, the government passed the Health Information Portability and Accountability Act, or HIPAA. We’ll look closer at that very important piece of legislation in later courses, but for now all you need to know is that HIPAA made the use of HCPCS mandatory in certain cases.

Coders today use HCPCS codes to represent medical procedures to Medicare, Medicaid, and several other third-party payers. The code set is divided into three levels. Level one is identical to CPT, though technically those codes, when used to bill Medicare or Medicaid, are HCPCS codes. CMS looked at the established CPT codes and decided that they didn’t need to improve upon or vary those codes, so instead they folded all of CPT into HCPCS.

To clarify: if you are coding, say, the placement of a tracheal stent for an elderly patient who is on Medicare, you would still use the CPT code 31631. However, because that code is going to Medicare, and not another payer, the code you’ve selected is technically a HCPCS code. For the most part this is just a technicality, but it can be confusing.

Where the real difference between CPT and HCPCS comes in is in Level II of HCPCS and the HCPCS modifiers. We’ll cover Level II codes here and work on HCPCS modifiers in the next course.

LEVEL II HCPCS CODES

Level II HCPCS codes are designed to represent non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that don’t fit readily into Level I. Where CPT describes the procedure performed on the patient, it doesn’t have many codes for the product used in the procedure. HCPCS Level II takes care of those products and pieces of medical equipment.

Level II codes are, like Level I, five characters long, but Level II codes are alphanumeric, with a letter occupying the first character of the code. These codes, like those in ICD and CPT, are grouped together by the services they describe, and are in numeric order.

You can generally refer to the range of codes by their initial character. J-codes, for example, are the codes for non-orally administered medication and chemotherapy drugs. J-codes are some of the most commonly used HCPCS Level II Codes.

For a full breakdown of HCPCS Level II codes by their alphabetic grouping, be sure to download our ebook.

HCPCS code manuals have an index and a large table of drugs. Whenever a coder is coding the delivery of a drug or medication, they should always use the drug table. Coding for medication is one of the most important parts of using HCPCS, and the drug table will provide much more accurate information on where to find the correct code.

Coders use HCPCS codes much like they would ICD or CPT codes. Upon receiving a medical report, you’d take notes on which procedure was performed, which products were prescribed, injected, or otherwise delivered to the patient, and then you’d use your HCPCS code set to find the appropriate code.

Be aware that when coding with HCPCS, you’re going to have to strive for an even higher level of specificity than with CPT. Since this code set has codes for all different variations and amounts of equipment and medicine, you’ll have to stay as close to the medical report as possible to make sure you’re coding the correct procedure. Look at it this way: 20 ten-mg capsules of antibiotics is going to cost more than ten ten-mg capsules, right? That’s what you have to watch out for with HCPCS.

Here’s an example. A patient receives an injection of 20 mg of adalimumab to temporarily relieve the signs of rheumatoid arthritis. If you received this medical report, leaving aside the CPT procedure code and the ICD diagnosis code, you’d look at the amount of medication and the type of medication. You’d also know, from going over the HCPCS Level II format, that you’re looking at a J-code—a drug administered any way except orally. A lot of J-codes are injected drugs, and that’s what we’re looking at in this example.

So, you’d look up adalimumab and find the J-code J0135, “injection, adalimumab, 20 mg.” That’s your HCPCS Level II code, and that’s what you’d put in if you were creating a claim for Medicare, Medicaid, or one of the many other payers that takes HCPCS codes.

Like CPT, HCPCS alerts you to which codes are new and which codes have been revised. New codes are listed with a circle, while revised codes have a triangle next to them. HCPCS is constantly being updated, and CMS, which maintains the code set, will often recycle codes. HCPCS features a number of strikethrough codes, and these let you know that a code that used to be listed there has been deleted and moved elsewhere.

You should also note that many codes in HCPCS Level II have specific guidelines for their use. Those guidelines are too various and fine grain to go over here, but you should know that with HCPCS, you always need to be paying attention. The diligent coder always takes note of the type of equipment used and the amount of medication delivered to the patient.

The other important variation HCPCS brings us is in the form of the HCPCS modifier. Since these modifiers are such commonly used elements of procedural coding, we’ll devote a short course to it directly following this one.HCPCS MODIFIERS

Now that we’ve become a little more familiar with the HCPCS code set, it’s time to take a look at HCPCS modifiers.

In an earlier course we talked about CPT modifiers. HCPCS modifiers work in almost exactly the same way. The two code sets are so similar, in fact, that you can regularly use modifiers from one codeset to the other. The HCPCS modifier –LT, for example, is regularly used in CPT codes when you need to describe a bilateral procedure that was only performed on one side of the body.

HCPCS modifiers, like CPT modifiers, are always two characters, and are added to the end of a HCPCS or CPT code with a hyphen. When differentiating between a CPT modifier and a HCPCS modifier, all there’s one simple rule: if the modifier has a letter in it, it’s a HCPCS modifier. If that modifier is entirely numeric, it’s a CPT modifier.

HCPCS modifiers, like CPT modifiers, provide additional information about a procedure or service without redefining the service provided. The hundreds of modifiers established in the HCPCS code set cover everything from a procedure’s Medicare eligibility to

It would take far too long to list all of the HCPCS modifiers so, for the sake of simplicity, we’ll stick to the list of HCPCS modifiers found in the CPT manual. Download our ebook for a copy of this list.

As you can see, these modifiers cover a broad scope of information. While most of the codes correspond to parts of the body, there are also modifiers for ambulance services and mammograms. If you look at the full list of HCPCS modifiers, you’ll also find modifiers that describe everything from the Medicare eligibility of a procedure to the number of wounds dressed on a single patient.

As with CPT codes, we always want to use modifiers for functionality first, and information second. That is, you’ll want to list the HCPCS modifier that directly affects reimbursement first. Remember that while certain coding forms provide space for multiple modifiers, payers don’t always look at modifiers listed after the first two.

Note that certain HCPCS modifiers don’t “agree” with certain CPT modifiers. The most obvious example of this would be CPT modifier -50 and the HCPCS modifiers –LT and –RT. These modifiers are mutually exclusive: CPT modifier -50 describes a bilateral procedure, while HCPCS modifiers –LT and –RT describe which side of the body a procedure is performed on.

Let’s look at a simplified example of an HCPCS modifier in action.

A patient is suffering from bronchitis and asthma. This patient has difficulty breathing and calls his doctor. The doctor advises the patient go directly to the emergency room. The doctor arranges with the hospital, which in this case would be the healthcare provider, to pick up the patient in an ambulance with basic life support systems, or BLS.

In order to code this procedure on a claim, we’d look at the A-codes of HCPCS, where the ambulance codes reside. There we’d find A0428, for “Ambulance service, basic life support, non-emergency transport.” That’s our base HCPCS code.

Since, however, the ambulance was provided by the healthcare provider and not, say, called in via 911, we should add a modifier to explain this. This may seem like splitting hairs, but how an ambulance is called can greatly affect the amount of money owed for a procedure.

In this case, we’d look for a modifier that pertains to ambulance service. We’d find the –QN modifier, for “Ambulance service furnished directly by a provider of services”—in other words, the hospital, the service provider, sent the ambulance over to pick up our patient.

We’d end up with this code: A0428-QN for a basic life support ambulance service, non-emergency transport, furnished by the provider of services.

Let’s look at another example, this time using a combination of CPT codes, CPT modifiers, and HCPCS modifiers.

A patient requires the drainage of a large, felon abscess on the tip of the middle finger of his left hand. A “felon” abscess is a complicated infection of the pulp on the distal, or last, phalanx of the hand. During the procedure, however, the patient becomes agitated and doctor decides to discontinue the procedure.

If we’re coding this procedure, we’d first look at the procedure performed. This is a procedure done to a patient, so we’re probably going to find it the CPT codebook. It’s also a surgical procedure, so we’d find it in the Surgery section of the codebook. Specifically, this is an incision—it’s drainage made via a cut to the skin.

Once in the surgery section, we’d flip to the musculoskeletal subsection and find the Hand and Fingers field of codes. There we’d find the codes for incision and see that there are two codes for drainage of a finger abscess: the parent code 26010 for “drainage of finger abscess; simple” and the indented code 26011 for “drainage of finger abscess; complicated (eg, felon).”

The abscess we’re draining is complicated—it’s even listed in the code as an example of a complicated abscess. So, we’d select the indented code and put 26011 as our base code.

Now we’d need to look at the additional information. What’s the more important code for reimbursement: the place on the hand where the procedure took place, or the fact that the procedure was discontinued? In this case, it’d be the discontinued procedure.

We’d add the CPT modifier -53 for discontinued procedure, and then we’d look at the HCPCS modifiers for where on the body the procedure was performed. If you’ll recall, some of the HCPCS modifiers we listed earlier have to do with parts of the hand. We’ll look at these modifiers and find the one that fits our need: F2, for “left hand, third digit.”

So our code would look like this: 26011-53-F2: a discontinued drainage of a complicated abscess on the third digit of the left hand.

Coding with HCPCS modifiers won’t always be as easy as that example, but that one should give you a good idea of how these additions to the code set help us code to the highest level of accuracy.

That concludes this course on HCPCS modifiers. Like the rest of the HCPCS code set, it’s easy to get overwhelmed by the number and variety of options available. Once you get the hang of HCPCS’s organizational structure, though, you should be able to easily navigate this important, useful code.

CROSSWALKING

Working in medical coding sometimes requires finding equivalencies between different code sets. The code sets CPT, HCPCS, and ICD are updated annually, and medical coders need to know how to find and map codes that may have changed between updates.

To do this, we perform a task called crosswalking. The term ‘crosswalking’ actually comes from computer science. Put simply, crosswalking is the mapping of equivalent, identical, or similar information across two or more distinct data sets. Put another way, when you crosswalk codes, you perform a coding translation between two sets, not unlike how coders translate medical reports into codes in the first place.

Code sets we’re translating between need to both describe the same thing. Bear in mind that crosswalking is not the process of finding the correct diagnosis code for a particular procedure. That’s the demonstration of medical necessity, and it’s an unavoidable part of the coding process. We’ll cover that in a little more depth later on and in our review .

Most crosswalking is done between two versions of the same code set. That is, a newer version and its older, now out-of-date version. For instance, the AMA updates the CPT code set every year, adding, changing the definitions or descriptions of, and deleting codes. For the most part, CPT and HCPCS make this easy for you by listing deleted and updated codes in appendices in the back of each code manual.

The real crosswalking challenge for the medical coder is between ICD-9-CM and ICD-10-CM. For decades, the ICD-9-CM system was used across U.S. healthcare venues to report diagnoses, but is now out of date and no longer able to effectively represent new medical diagnoses. The current coding system, ICD-10-CM, was implemented on October 1, 2015. This system is significantly larger and more flexible than its predecessor, thanks to its new format.

CROSSWALKING BETWEEN ICD-9-CM AND ICD-10-CM

To review, ICD-9-CM had five characters and was primarily numeric, with a few alphanumeric codes used in certain situations. ICD-10-CM, on the other hand, is seven characters long and entirely alphanumeric. Where each ICD-9-CM code could have one subcategory and one subclassification, an ICD-10-CM code can have one subcategory and two subclassifications, in addition to an alpha extension that provides information as to which visit, or encounter, this is with the patient’s particular illness or injury. ICD-10-CM is obviously a much more extensive, detail-oriented code set, and its new format and organization presented coders with a challenge during the transition period.

In some cases, coders may still need to translate codes back and forth from one set to the other. If, for instance, you are looking at a patient’s medical history from 2009, it may be necessary to crosswalk those ICD-9-CM codes forward to ICD-10-CM to comply with contemporary coding standards.

The new ICD-10-CM format makes this crosswalking process difficult. Remember, as coders, we always have to be as exact as possible. But because of the increased number of subclassifications, the higher specificity (including ICD-10-CM’s use of laterality and information regarding location on the body), and ICD-10-CM’s organization, less than a quarter of ICD-10-CM codes have an exact match in ICD-9-CM.

So how should we approach the crosswalking process? The best place to start is by breaking down the types of matches there are between code sets. The AMA has classified four types of matches between ICD-9-CM and ICD-10-CM. Let’s take a look at them now.

ONE-TO-ONE EXACT MATCHES

In these matches, one code set (the source) has an exact match, down to the wording, in the other code set (the target).

ONE-TO-ONE APPROXIMATE MATCHES WITH ONE CHOICE

Notably more common than exact matchces, approximate matches with one choice make up a majority of the crosswalking procedure. 82.6 percent of ICD-10-CM codes can be crosswalked back to ICD-9-CM as approximate matches with one choice, and 49.1 percent can be mapped in the other direction. Matches like this describe a “close-enough” pairing for two codes.

ONE-TO-ONE APPROXIMATE MATCHES WITH MULTIPLE CHOICES

While exact and approximate matches with only one choice make up the majority of crosswalked codes, coders will occasionally run into coding crosswalks that are less specific. The first of these is an approximate match with multiple choices. In instances of multiple-choice matches, a coder may find two or more options in one code set that correspond to a single code in another set. In situations such as this, it’s up to the coder to decide which of the choices of codes works best for the particular claim.

ONE-TO-MANY MATCHES

This is the most difficult and time-consuming type of ICD-10-CM/ICD-9-CM crosswalk. In one-to-many matches, a code in the source set must be created out of multiple codes in the target set.

In one-to-many matches, a single code in one set must be crosswalked to a “cluster” of codes in the other set. Clusters are always between two and four codes. There may be multiple target clusters for a single source code. It’s up to the coder to look at and abstract all of the concepts in the single source code, and find their corollaries in the target code set. This process of crosswalking by cluster requires diligence and a lot of review, as a missing code from one of the clusters can drastically affect the status of a claim or report.

NO MATCH

In certain cases, there is simply no match between code sets. This typically only happens in cases of crosswalking ICD-10-CM back to ICD-9-CM. In these instances, coders may use the phrase “NoDX” to show that there is no target diagnosis code that matches the source code.

GENERAL EQUIVALENCY MAPPINGS (GEMS)

Crosswalking between ICD-10-CM and ICD-9-CM became an extremely important skill for coders to learn during the transition period from ICD-9 to ICD-10. In order to help coders, the National Center for Health Statistics created a set of tools, called General Equivalency Mappings, or GEMs. GEMs are like guides that list a code from one set and its exact, possible, or appropriate match in the other set. These GEMs will be maintained for at least three years beyond the October, 2015 ICD-10 implementation date, by the CMS and CDC.

(Like many aspects of the crosswalking process, GEMs can be very intimidating, and they’re difficult to fully understand without a thorough knowledge of the medical coding practice itself. For reasons of brevity and space, we won’t be discussing them in great detail in this course, other than in general terms. If you’d like to learn more about GEMs, how they work, and how to use them, you can find a thorough, comprehensive guide here.)

One of the main things we learn from looking at GEMs is which codes can be transferred from one set to another. One of the main rules of crosswalking is: You can code from a specific injury to a general one, but you cannot code from the general to the specific.

That is, you can’t infer specific pieces of information from a more general diagnosis code and then apply them to a more specific code in another set.

Because crosswalking requires a thorough understanding of both ICD-10-CM and ICD-9-CM, we won’t dive much deeper than that in this course. As you train to become a medical coder, you may be required to take extra courses that instruct you how to map codes effectively between the two sets. Having a fluency in the crosswalking process will make you a more desirable hire.

PLEASE DO LIKE??