Insurance companies cover various healthcare services; however, the eligibility or patient coverage is ensured/verified before the amount is paid. These reimbursements depend highly on accurate information and the use of correct codes in medical claims. Medical coding is a process involving the translation of the information in a patient’s medical record into specific codes. Various types of medical coding systems are being used by medical billers, out of which CPT, HCPCS level II, & ICD-10 codes are used commonly.
Difference between CPT & HCPCS codes
Below is the list of CPT codes Vs. HCPCS codes:
|Terms||HCPCS Level II codes||CPT Codes|
|Significance||HCPCS codes are for basic healthcare services like medical devices, medical supplies, etc. These codes provide a standardized description of the services.||CPT codes are for services like surgeries, diagnostic tests, evaluation and management services (E&M), etc.|
|Divisions||They are divided into three levels, i.e., Level I, Level II, and Level III.||They are divided into three categories i.e., Category I, Category II, and Category III.|
|Published or created by||Published and maintained by the CMS (Centers for Medicare and Medicaid Services)||Published and maintained by the American Medical Association (AMA).|
|Purpose or affect||These codes directly affect the healthcare providers as well as the non-frontend healthcare providers.||These codes are for the procedures and services provided by the healthcare provider to the patients.|
|Who can use it?||These codes are entitled to everyone to use – free access||In order to access the CPT codes, outsiders have to pay for the services.|
Following, you will find the detail on CPT Vs. HCPCS codes
CPT Codes in medical billing:
CPT stands for Current Procedural Terminology codes – offering healthcare providers a unique language for billing medical services or procedures. Along with that CPT codes also streamlines reporting as well as increase efficiency and accuracy. CPT code set is maintained and published by the American Medical Association (AMA). These codes represent a lot of healthcare services or procedures for medical billing, including:
- Diagnostic tests
- Other medical procedures or services performed
CPT code set comprises thousands of codes describing various healthcare services. For medical billing, proper use of CPT codes is an integral part. These codes describe the procedure performed by the healthcare provider, physician, or professional.
Types of CPT codes
There are three major types/categories of CPT codes:
These category codes are the most commonly used codes by medical coders to report services and procedures. CPT codes are updated by the American Medical Association (AMA) annually. Category I codes are five-digit numeric codes only. These codes range from 00100 to 99499. This category is further divided into six large sub-categories, as follows:
- Evaluation and management services
- Anesthesiology services
- Radiology services
- Pathology and laboratory services
- Medicine services and procedures.
Each field of CPT code sets comes with its own set of guidelines on how and where to use them. Following is the list of sub-categories of Category I along with their corresponding code ranges:
- 00100-01999 – Anesthesia
- 10004-69990 – Surgery
- 70010-79999 – Radiology Procedures
- 80047-89398 – Pathology and Laboratory Procedures
- 90281-99607 – Medicine Services and Procedures
- 99091-99499 – Evaluation and Management Services
This category comprises codes for performance measurement. Category II codes are supplemental tracking codes. These alphanumeric codes comprise four digits ending with an “F.” These codes are optional, meaning they are not required for proper medical coding. Category II codes range from 0001F-9007F.
- 0001F-0015F – Composite Measures
- 0500F-0584F – Patient Management
- 1000F-1505F – Patient History
- 2000F-2060F – Physical Examination
- 3006F-3776F – Diagnostic/Screening Processes or Results
- 4000F-4563F – Therapeutic, Preventive or Other Interventions
- 5005F-5250F – Follow-up or Other Outcomes
- 6005F-6150F – Patient Safety
- 7010F-7025F – Structural Measures
- 9001F-9007F – Non-Measure Category II Codes
This category comprises temporary codes for emerging technology, procedures, and services. They are alphanumeric codes, i.e., four digits ending with a “T.” Category III codes range from 0042T- 0737T.
Certain procedures can be covered under the codes for the unlisted procedure in Category I codes. However, if a code exists in Category III, you are required to use that code. For instance, the 0479T CPT code is for when:
“The provider creates openings or windows (fenestrations) in burns and traumatic scars using a fractional ablative laser technique. Report this code for the first 100 cm2 in adults or 1 percent of body surface area (BSA) in infants and children. “
- Various Services – Category III Codes
- Atherectomy (Open or Percutaneous) for Supra-Inguinal Arteries and Other Undefined Category Codes
- Imaging, Testing, Implantation, and Other Services
- Adaptive Behavior Assessments
- Other Procedures and Assessments
- Pacemaker – Leadless and Pocketless System
- Phrenic Nerve Stimulation System Procedures
- Imaging, Evaluation, Programming, and Recording Procedures
- Laser Ablation Procedures
- Blood Products Transfusion Procedure
Medical and healthcare procedures are complicated as it is, which means when it comes to medical coding, additional information is required. CPT modifiers do just that; these modifiers provide any additional information required regarding the service or procedure performed. These modifier(s) may provide additional but useful information regarding
- Number of procedures or services performed (if more than one)
- The medical necessity behind performing that particular procedure
- The place of service, i.e., where the healthcare service was performed and how many locations.
- Whether the procedure was bilateral
- The number of surgeons who performed the procedure (if more than one)
- The procedure was reduced or provided more than typically performed.
- And any other information that is crucial for proper medical billing and reimbursement.
Structure of the CPT Modifiers:
CPT modifiers contain two characters; they can be alphanumeric or numeric. However, mostly used modifiers are numeric, for instance, modifier 22, modifier 59, etc. Some of the most commonly used CPT modifiers include:
Modifier 25 in medical billing represents “significant, separately identifiable evaluation and management (E&M) services by the same physician or another healthcare physician on the same day of the procedure or other service”.
This modifier is defined as the professional component (PC). This professional component may include the services of a physician, including a technician’s supervision or interpretation of the test results. Modifier 26 should be used when a physician provides their services but hasn’t performed the test themselves.
Modifier 59 in medical billing stands for a “distinct procedural service”. In some instances, a healthcare physician might be required to indicate that a service was distinct and independent of the other service(s) performed on the same day.
However, this modifier is one of the most misused modifiers in medical billing. Modifier 59 should be used as a last resort; it is only appropriate to use if no other suitable modifier applies. Documentation is also essential, along with using modifier 59 containing the information to back the use of it, i.e., highlighting the services were performed separately.
The term HCPCS stands for Healthcare Common Procedure Coding System. This set of codes is updated annually by CMS. In medical billing when the HCPCS code set is being discussed, it is refers to HCPCS Level II national code sets. HCPCS Level II code set is for the healthcare providers, physicians, and medical equipment suppliers. When billing for healthcare claims, this code set is for services like
- Medical devices
- Medical supplies
- Medical transportation services
- Other items and services
Levels of HCPCS codes:
HCPCS codes comprise three levels in total,
Level I codes are the ones maintained and published by the American Medical Association (AMA), i.e., CPT codes. These codes describe medical, surgical, and diagnostic services provided by healthcare physicians or providers.
This level comprises codes that are non-physician services or procedures. Level II HCPCS codes represent services like
- Ambulance services
- Durable medical equipment
- And other medical services
Lastly, level III HCPCS codes are the local codes and are not nationally accepted. HCPCS Level III codes are alphanumeric codes, starting with an alpha character, X or Z.
HCPCS level II codes, as well as the modifiers, are maintained by the Centers for Medicare and Medicaid Services (CMS). These modifiers are either alphanumeric or just have two letters. Some of the examples of HCPCS level II modifiers include:
This modifier is for when a service is performed on the upper left eyelid.
A separate structure is a service that is distinct because it was performed on a separate organ/structure. This modifier is for surgical, non-surgical therapeutic, as well as diagnostic procedures that aren’t usually encountered on the same day.
This modifier is used for billing the technical component (TC) of the procedure when both components/portions exist in one procedure code. Modifier TC should be used when a test is performed by the physician but they don’t interpret.
Medical coding in medical billing
Along with the above-mentioned code sets (HCPCS & CPT), ICD-10 codes are also one of the common coding systems in medical billing. Medical coding is a complex process, hence, it comes with a higher risk of errors or mistakes. There are several errors for CPT as well as HCPCS codes in medical coding. Some of the most common medical coding errors include the following:
Use of incorrect code
Even a minor mix-up of digits or alphabets can result in the use of an incorrect code, leading to claims being denied or rejected. Therefore, loss of payments, revenues, and reimbursements.
Using multiple codes to report a procedure when a comprehensive code exists is known as unbundling. It means reporting individual parts of a single procedure separately. Unbundling is Medicare abuse.
Incorrect documentation can lead to the use of incorrect CPT or HCPCS codes, therefore, claim denials or rejections. This is one of the reasons why correct, accurate, and complete documentation is essential for proper medical billing and coding.
When a provider reports a more expensive or comprehensive procedure code than the service performed is referred to as upcoding. For instance, billing for 40-60 minutes when the physician spent 15 minutes with the patient.
Under coding refers to when the healthcare providers fail to report all the procedures performed.
Not following/failing to check with the NCCI edits when billing multiple coding
The Centers for Medicare and Medicaid Services have developed complete guidelines and coding methods for the billers to follow, known as NCCI edits. This ensures that inappropriate payments are being avoided for Medicare.
Not using the appropriate modifier or using an inappropriate modifier
Note that modifiers in medical billing aren’t supposed to change the meaning of the code; they just provide additional information regarding the procedure performed. Now, using the correct modifier is essential for proper medical billing.
Overuse of modifier 22
Modifier 22 refers to “Increased procedural service.” This modifier is used to report that a physician had to perform more work/service than is usually required for that procedure. For using modifier 22, proper documentation is required to explain why extra work was needed.
Incorrect use of injection codes
It includes using multiple codes for an entire session during which injections were administered. Only one code needs to be used for this.
Reporting or billing unlisted codes without documentation
Proper documentation is required for billing the unlisted procedure or services.
Frequently Asked Questions (FAQs)
When to use HCPCS Vs. CPT codes?
CPT codes represent a lot of healthcare services or procedures for medical billing. It includes surgeries, diagnostic tests, evaluations, and other medical procedures or services performed. However, HCPCS codes are based on CPT codes when healthcare is delivered to provide standardized coding.
CPT Vs. HCPCS II codes, how to bill?
Medical billers should be compliant with the official guidelines provided for billing and coding CPT and HCPCS Level II codes.