Payment, Utilization Review (UR), and Coverage Information on CMS Quarterly

20.8 - Payment, Utilization Review (UR), and Coverage Information on CMS Quarterly HCPCS Codes Update File (Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020) The file CMS provides for the quarterly update of HCPCS codes contains fields for payment, UR, and coverage information to assist in developing front-end edit screens. Coverage information is not all inclusive, but should be used mainly as a guide in establishing specific review limits. A/B MACs (B) must establish reasonable developmental guidelines, review screens, and relative value units, as appropriate. A/B MACs (B) must assure that their system processes claims in accordance with CMS policies and procedures, including changes that may occur between HCPCS codes updates. Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as Level II codes/modifiers prefixed with “Q” or “K” or “G.” Questions may arise in updating that require A/B MAC (B) staff to refer to a physician’s or supplier’s pricing history. Therefore, keep an electronic backup of HCPCS codes for the two prior years with linkages to pricing profiles. Perform required computer analysis as necessary. The HCPCS terminology seldom includes a place of service designation. Where place of service affects pricing, pricing is obtained from the place of service field on the claim record. A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage policies from CMS. A/B MAC