HCPCS - General Information

What's New

The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set.  These changes are included in the 2013 HCPCS Annual Update, which has been published on CMS’ HCPCS Web site at:  

Changes are effective on the date indicated on the update.

CMS is now providing the HCPCS Level II code long descriptors in mixed case (instead of in ALL CAPS).  Aside from the difference in case, there are no changes to the long descriptors.  This change is being made under guidance from the CMS Office of Communications to comply with the Plain Writing Act of 2010, which requires that federal agencies use clear Government communication that the public can understand and use.  The HCPCS Level II code long descriptors appear on the Medicare Summary Notice ((MSN), the explanation of benefits sent quarterly to Medicare beneficiaries).  This is part of a larger effort to make the entire MSN more consumer friendly.  Our research shows that mixed case is easier for people to read and understand.

The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set.  These changes have been posted to the HCPCS website at http://www.cms.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.  Changes are effective on the date indicated on the update.

In response to shortage of liposomal doxorubicin (Doxil), the FDA is permitting the temporary importation of Lipodox, a brand of liposomal doxorubicin hydrochloride.  See
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm292658.htm.  The Centers for Medicare & Medicaid Services’ (CMS) HCPCS Quarterly update includes 2 new codes (Q2048 and Q2049) for liposomal doxorubicin that will become effective July 1, 2012.  The code descriptors are worded in a manner that distinguishes Lipodox and Doxil.  As of July 1, 2012, HCPCS code J9001 will not be used for Medicare billing.  CMS will release a Change Request (CR) with additional instructions in the near future. 

Errata dated November 12, 2009 for the Negative Pressure Wound Therapy Devices report will be posted April 12, 2010 at:   (http://www.ahrq.gov/clinic/techix.htm) under “2009.”  

These errata include three minor corrections. First, language in the attrition diagrams has been corrected to reflect the fact that meeting abstracts, meeting poster presentations, coding documents and other items were obtained and screened at the same point in the process as full published articles. The full published articles had previously been through screening of their study abstracts. Consequently, it was more appropriate to use the term “documents” to described items screened against the full set of inclusion criteria.

Next, the study count included in Appendix A has been corrected to accurately reflect the 137 studies identified by our searches and subsequently included in the report.

Lastly, Table 13, the Excluded Documents table, has been renamed and corrected to reflect that 151 documents were excluded at the “article level.” (Six citations that had been previously listed in Table 13 were subsequently removed since they had actually been excluded at the “abstract level.”)  As noted above, the documents listed in Table 13 included published studies, meeting abstracts, conference presentations, or other retrieved documents identified in our electronic and manual searches.

The Centers for Medicare & Medicaid Services have partnered with the Agency for Healthcare Research and Quality (AHRQ) to commission a review of Negative Pressure Wound Therapy (NPWT) devices. The purpose of this review is to provide information to the Centers for Medicare & Medicaid Services (CMS) for consideration in Healthcare Common Procedure Coding System (HCPCS) coding decisions. Section 154(c) (3) of the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) calls for the Secretary of Health and Human Services to perform an evaluation of the HCPCS codes for NPWT devices.

The HCPCS Level II coding system is a comprehensive, standardized system that classifies similar products that are medical in nature into categories for the purpose of efficient claims processing. Products are classified based on similarities in function and whether the products exhibit significant therapeutic distinctions from other products. This review will facilitate CMS' evaluation of HCPCS coding for NPWT by providing CMS with relevant studies and information for use in consideration of coding changes, as required by the MIPPA legislation. CMS will use this review in its assessment of whether existing HCPCS codes adequately represent the technology and comparative benefits of NPWT devices.

This review is one of several that are being conducted for the AHRQ Technology Assessment Program. It will include a review of all available literature on the topic and a solicitation from all interested stakeholders including health care professionals, scientific researchers, wound care organizations, biotech industry, and the patient wound care community for studies and other compelling clinical evidence regarding clinical outcomes associated with NPWT devices. We are particularly interested in those well-conducted clinical trials that describe the comparative benefits of these devices.

The solicitation for studies and evidence was made available to industry stakeholders on December 30, 2008, and requested stakeholders provide this information to AHRQ by February 06, 2009. 

HCPCS Background Information

Each year, in the United States, health care insurers process over 5 billion claims for payment. For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II Code Set is one of the standard code sets used for this purpose. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), 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 and procedures furnished by physicians and other health care professionals. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Level I of the HCPCS, the CPT 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 durable medical equipment, prosthetics, orthotics, and supplies (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. The development and use of level II of the HCPCS began in the 1980's. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.

In October of 2003, the Secretary of HHS delegated authority under the HIPAA legislation to CMS to maintain and distribute HCPCS Level II Codes.  As stated in 42 CFR Sec. 414.40 (a) CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. Within CMS there is a CMS HCPCS Workgroup which is an internal workgroup comprised of representatives of the major components of CMS, as well as other consultants from pertinent Federal agencies.   Prior to December 31, 2003, Level III HCPCS were developed and used by Medicaid State agencies, Medicare contractors, and private insurers in their specific programs or local areas of jurisdiction. For purposes of Medicare, level III codes were also referred to as local codes. Local codes were established when an insurer preferred that suppliers use a local code to identify a service, for which there is no level I or level II code, rather than use a "miscellaneous or not otherwise classified code." The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required CMS to adopt standards for coding systems that are used for reporting health care transactions. We published, in the Federal Register on August 17, 2000 (65 FR 50312), regulations to implement this part of the HIPAA legislation. These regulations provided for the elimination of level III local codes by October 2002, at which time, the level I and level II code sets could be used. The elimination of local codes was postponed, as a result of section 532(a) of BIPA, which continued the use of local codes through December 31, 2003.