Use and Acceptance of HCPCS Codes and Modifiers

20.3 - Use and Acceptance of HCPCS Codes and Modifiers (Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020) The HCPCS is updated quarterly to reflect changes in the practice of medicine and provision of health care. The CMS provides a file containing the updated HCPCS codes to A/B MACs (A), (B), (HHH), and DME MACs and Medicaid State agencies 60 to 90 days in advance of the implementation of each update. Distribution consists of an electronic file of the updated HCPCS codes, file characteristics, record layout, and a listing of added, revised and deleted codes. MACs are required to update their HCPCS codes file and map all new, revised, and deleted codes to appropriate payment information. An updated list of the HCPCS codes for Durable Medical Equipment Medicare Administrative Contractors (DME MAC) and A/B MAC (B) jurisdictions is updated quarterly to reflect codes that have been added or discontinued (deleted) during each year. A recurring update notification will be published to notify the DME MACs and A/B MACs (B) that the list has been updated and is available on the CMS Web site. https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. Both the DME MACs and the A/B MACs (B) publish this list to educate providers on which MAC they should bill for codes provided on this list. Physicians and suppliers must use HCPCS codes on the Form CMS-1500 or its electronic equivalent and providers must use HCPCS codes on the Form CMS-1450 or its electronic equivalent for most outpatient services. The procedure, item, or service can be further described by using 2-position modifiers contained in HCPCS. Modifiers to HCPCS Level I codes for medicine, anesthesia, surgery, radiology, and pathology are on the HCPCS codes file from CMS. Modifiers for Level II alpha-numeric codes are with the Level II codes published by CMS. Alpha-numeric and CPT-4 modifiers may be used with either alpha-numeric or CPT-4 codes. A/B MACs (A, B and HHH) and DME MACs are required to accept up to four 2-position numeric or alpha modifiers and process both modifiers completely through the claims processing system (including any manual portion) as far as payment history. It is not acceptable merely to be able to accept multiple modifiers and then drop one before complete systems processing. Dropping of a modifier leads to incomplete and inaccurate pricing profiles. Series “Q,” “K,” and “G” in the Level II coding are reserved for CMS assignment. “Q,” “K,” and “G” codes are temporary national codes for items or services requiring uniform national coding between one year’s update and the next. Sometimes “temporary” codes remain for more than one update. If “Q,” “K,” or “G” codes are not converted to permanent codes in the Level I or Level II series in the following update, they will remain active until converted or until CMS notifies MACs to delete them. All active “Q,” “K,” and “G” codes at the time of update will be included on the update file for MACs. In addition, deleted codes are retained on the file for informational purposes, with a deleted indicator, for four years. Series “S” Level II codes are reserved for use by the BCBSA and other private insurers. These codes provide for reporting needs unique to those organizations. Each State defines its own Medicaid coverage, payment, and utilization levels. The CMS does not impose Medicare requirements on Medicaid programs. The HCPCS simply provides a system for identifying services that can be expanded to meet everyone’s needs.