Which payer will require the HCPCS code instead of the CPT?
Asked by: Prince Morar | Last update: April 23, 2025Score: 4.5/5 (36 votes)
When to use HCPCS vs cpt?
Some CPT codes are even used internationally. Medical providers often use these codes to describe and document the services they offer, in addition to using them for billing purposes. On the other hand, HCPCS codes are used to bill for a much smaller, more specific range of medical services.
What payers use HCPCS codes?
The Healthcare Common Procedure Coding System (HCPCS) is a collection of standardized codes used in medical billing to represent various medical procedures, services, products and supplies in claims to Medicare, Medicaid, and many third-party payers.
What are some examples of services that require HCPCS codes?
HCPCS Level II: A standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes, such as ambulance services or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.
What type of insurance are HCPCS codes used for?
The Healthcare Common Procedure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.
The Difference Between HCPCS and CPT Codes
Who uses HCPCS codes?
Healthcare Common Procedure Coding System (HCPCS) is a standardized code system necessary for medical providers to submit healthcare claims to Medicare and other health insurances in a consistent and orderly manner. HCPCS includes two medical code sets, HCPCS Level I and HCPCS Level II.
Does Medicare prefer CPT or HCPCS codes?
Today, the CPT coding system is the preferred system for coding and describing healthcare services and procedures in federal programs (Medicare and Medicaid) and throughout the United States by private insurers and providers of healthcare services.
What revenue codes require HCPCS?
HCPCS Clarification
The applicable revenue codes are: 250, 251, 252, 254, 255, 257, 258, 259, 260, 262, 263, 264, 269, 270, 271, 272, 274, 275, 276, 278, 279, 280, 289, 290, 370, 371, 372, 379, 390, 399, 560, 569, 621, 622, 624, 630, 631, 632, 633, 637, 700, 709, 710, 719, 720, 721, 762, 810, 819, and 942.
What organization requires HCPCS codes for reimbursement?
Which regulatory agency issues HCPCS codes? There are two organizations that issue HCPCS codes: The Centers for Medicare & Medicaid Services (CMS), located in Baltimore, Maryland, is the agency that issues new HCPCS codes. CMS uses a HCPCS Workgroup to make its decisions on new codes.
Are HCPCS G codes for Medicare only?
As G codes are part of the national HCPCS Level II code set, they may also be used by non-Medicare insurers.
Do medications have HCPCS codes?
The billing and payment codes (Healthcare Common Procedure Coding System (HCPCS) codes) identified specifically pertain to drugs in single-dose containers.
Do commercial payers use CPT codes?
While Medicare has its own coding system (HCPCS) for billing Medicare for procedures (based on CPT codes), the vast majority of commercial insurers still rely on CPT.
What CPT codes are changing for 2024?
Several Category III codes will be converted to Category I codes in the Current Procedural Termi- nology (CPT®) 2024 code set, these include: dorsal sacroiliac (SI) arthrodesis; coronary fractional flow reserve (FFR) with computerized tomography (CT); coronary intravascular lithotripsy (IVL) interventions; ...
When did HCPCS become mandatory for coding and billing?
Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.
How do you know when to use HCPCS modifiers?
Medical coders and healthcare providers use these modifiers to explain what happened during a particular encounter. For instance, a coder may use an HCPCS modifier to indicate that: Service didn't happen exactly as described by an HCPCS Level I or Level II code descriptor.
Can CPT and HCPCS be billed together?
Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a provider/supplier reports the 2 codes of an edit pair, the Column Two code is denied, and the Column One code is eligible for payment.
When to use HCPCS code?
HCPCS allows physicians to document the services provided. These codes are added to insurance claims and submitted to insurance companies for payment. Accurate and appropriate coding for the services you provide in your practice is vital, not only for payment purposes, but also for documentation purposes.
Do all private payers use HCPCS codes?
National HCPCS Level II Codes
CMS is responsible for making decisions about additions, revisions, and deletions to the national alpha-numeric codes. These codes are for the use of all private and public health insurers.
What is the difference between CPT and HCPCS?
CPT codes are divided into three categories: Category I, II, and III. HCPCS codes are divided into primary levels: Level I (CPT-4) and Level II. CPT codes are owned and maintained by the American Medical Association (AMA). HCPCS codes are owned and maintained by the Centers for Medicare and Medicaid Services (CMS).
Are Hcpcs codes required on inpatient claims?
For an inpatient facility claim, the ICD-10-PCS codes are used to show what services provided. You wouldn't typically see a CPT or HCPC associated with most revenue codes on an inpatient facility claim. Outpatient facility claims will have a CPT listed with Revenue Code 360 to show what surgery was performed.
What is the difference between a CPT code and a revenue code?
Revenue codes tell what medical service was provided. Medical codes tell why and how. For example, a revenue code may indicate that a patient received physical therapy. The CPT code would specify exactly what therapy services were performed, like therapeutic exercises or neuromuscular reeducation.
Does rev code 370 require HCPCS?
Revenue Code 370 is an exempt revenue code and does not require a HCPCS code for payment.
What CPT codes are not covered by Medicare?
Certain services are never considered for payment by Medicare. These include preventive examinations represented by CPT codes 99381-99397. Medicare only covers three immunizations (influenza, pneumonia, and hepatitis B) as prophylactic physician services.
Does Medicaid use HCPCS codes?
Healthcare providers use Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes to report medical services performed on patients to state Medicaid agencies or fiscal agents. HCPCS consists of Level I CPT codes and Level II codes.
Who can use CPT codes?
CPT codes are the numerical codes used to identify medical services and procedures furnished by qualified healthcare professionals (QHPs).