The Healthcare Common Procedure Coding System (HCPCS) was established by the Centers for Medicare and Medicaid Services (CMS) in 1983. HCPCS used to stand for HCFA Common Procedure Coding System when CMS used to be the Health Care Financing Administration (HCFA) prior to June 14, 2001. Since August 2000, HCPCS is used to report hospital outpatient services and physician services that participate in the Medicare Outpatient Prospective Payment Systems (OPPS), for reimbursement by CMS to hospitals for outpatient services.
HCPCS is divided into two principle subsets, referred to as Level I and Level II. Level I of HCPCS is comprised of the Current Procedural Terminology (CPT), a coding system maintained by the American Medical Association (AMA). These codes are used primarily to identify services and procedures furnished by physicians and other healthcare professionals. CPT does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians – which would be covered by HCPCS level II.
Level II of HCPCS is used primarily to identify products, supplies, and services not included in CPT, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. HCPCS level II codes were established for these services and supplies to be able to be billed to and paid for by Medicare and other insurers.
HCPCS codes are alphanumeric 5-character codes beginning with a letter followed by 4 numeric digits, and divided into several types depending on the purpose for the code:
- Permanent national codes – these cover the bulk of the healthcare procedures and services reimbursable under OPPS; updated annually and effective January 1st. Examples:
A0430 Ambulance service, conventional air services, transport, one way (fixed wing)
B4081 Nasogastric tubing with stylet
E0117 Crutch, underarm, articulating, spring assisted, each
J0120 Injection, tetracycline, up to 250 mg
L3040 Foot, arch support, removable, premolded, longitudinal, each
M0075 Cellular therapy
P2031 Hair analysis (excluding arsenic)
R0070 Transportation of portable x-ray equipment and personnel to home or nursing
home, per trip to facility or location, one patient seen
V2599 Contact lens, other type
- Dental codes – starts with a D; these are from the Current Dental Terminology (CDT), owned and maintained by the
American Dental Association (ADA). Example:
D0150 Comprehensive oral evaluation
- Miscellaneous/not otherwise classified codes – these allow suppliers to begin billing immediately for a service or item as soon as it is approved by the
Food and Drug Administration (FDA), before a HCPCS code has been assigned; or may be a rare service. Examples:
A4649 Surgical supply; miscellaneous
A9999 Miscellaneous DME supply or accessory, not otherwise specified
J3490 Unclassified drugs
L8499 Unlisted procedure for miscellaneous prosthetic services
V5299 Hearing service, miscellaneous
- Temporary codes – used for meeting, within a short time frame, the national program operational needs of a particular insurance sector, that are not addressed
by an already existing national code. These codes can be added, changed or deleted on a quarterly basis, and may be replaced by permanent codes.
- Codes starting with a C (“C codes”) are reported for device categories, new technology procedures, and drugs, biologicals and radiopharmaceuticals that do not have other HCPCS code assignments. Example: C9899 Implanted prosthetic device, payable only for inpatients who do not have inpatient coverage.
- The G codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. Codes to report demonstration projects are included in this section. Example: G0008 Administration of influenza virus vaccine.
- Certain H codes are used by those state Medicaid agencies that are mandated by state law to establish separate codes for identifying mental health services such as alcohol and drug treatment services. Example: H0001 Alcohol and/or drug assessment.
- The Q codes are used to identify services that would not be given a CPT code or a permanent national code but are needed for claims processing purposes. Example: Q0113 Pinworm examinations.
- The K codes are used for durable medical equipment (DME) not currently covered by the permanent national codes. Example: K0001 Standard wheelchair.
- The S codes are primarily used by private insurers to implement policies, programs, or claims processing. These codes may also be used by Medicaid programs, but they are not payable by Medicare. Example: S0028 Injection, famotidine, 20 mg.
- The T codes are for use primarily by Medicaid state agencies. These codes may be also used by private insurance programs, but they are not payable by Medicare. Example: T1001 Nursing assessment/evaluation.
You can find more information regarding HCPCS code on the CMS website. If you have other terminology topics that you’d like us to discuss, or need help with terminology implementation or mapping, please contact us!