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Questions and Answers
Which of the following key terms is defined as: Codes that ensure uniform reporting of medical products or services on claims?
Which of the following key terms is defined as: Codes that ensure uniform reporting of medical products or services on claims?
- CMS HCPCS workgroup
- DME
- HCPCS level II (correct)
- DMEPOS dealer
Which of the following key terms is defined as: Supply patients with DME (e.g., canes, crutches, walkers, commode chairs)?
Which of the following key terms is defined as: Supply patients with DME (e.g., canes, crutches, walkers, commode chairs)?
- DMEPOS dealer (correct)
- Modifiers
- Permanent codes
- DME MAC
Which of the following key terms is defined as: Includes artificial limbs, braces, medications, surgical dressings, and wheelchairs?
Which of the following key terms is defined as: Includes artificial limbs, braces, medications, surgical dressings, and wheelchairs?
- Miscellaneous codes
- DMEPOS (correct)
- CMS
- DME
Which of the following key terms is defined as: Develop and maintain HCPCS level II codes?
Which of the following key terms is defined as: Develop and maintain HCPCS level II codes?
Which of the following key terms is defined by Medicare as equipment that can withstand repeated use?
Which of the following key terms is defined by Medicare as equipment that can withstand repeated use?
Which of the following key terms is attached to any code to clarify services and procedures performed by providers?
Which of the following key terms is attached to any code to clarify services and procedures performed by providers?
Which of the following key terms is used by all private and public health insurers?
Which of the following key terms is used by all private and public health insurers?
Which of the following key terms refers to temporary additional payments (over and above the OPPS payment)?
Which of the following key terms refers to temporary additional payments (over and above the OPPS payment)?
Which of the following key terms allow payers flexibility to establish these codes as needed before the next annual update?
Which of the following key terms allow payers flexibility to establish these codes as needed before the next annual update?
Which of the following key terms is reported when there is no existing HCPCS level II code?
Which of the following key terms is reported when there is no existing HCPCS level II code?
CMS decided to have all DME claims processed by only four DME MACs to reduce ___________ claims.
CMS decided to have all DME claims processed by only four DME MACs to reduce ___________ claims.
Providers and DMEPOS dealers obtain annual lists of valid HCPCS level II codes, which include ___________ instructions for services.
Providers and DMEPOS dealers obtain annual lists of valid HCPCS level II codes, which include ___________ instructions for services.
For certain items or services reported on a claim submitted to the DME MAC, the DMEPOS dealer must receive a signed certificate of medical _______________.
For certain items or services reported on a claim submitted to the DME MAC, the DMEPOS dealer must receive a signed certificate of medical _______________.
When a physician treats a Medicare patient for a fractured femur and supplies the patient with crutches, two claims are generated. The physician's claim for the fracture care is sent to the MAC, and the claim for the crutches is sent to the _________ __________.
When a physician treats a Medicare patient for a fractured femur and supplies the patient with crutches, two claims are generated. The physician's claim for the fracture care is sent to the MAC, and the claim for the crutches is sent to the _________ __________.
The specific HCPCS level II code determines whether the claim is sent to the MAC that processes provider claims or the _______ _______ that processes DMEPOS dealer claims.
The specific HCPCS level II code determines whether the claim is sent to the MAC that processes provider claims or the _______ _______ that processes DMEPOS dealer claims.
HCPCS level II codes are five characters in length, and they begin with letters _____ followed by four numbers.
HCPCS level II codes are five characters in length, and they begin with letters _____ followed by four numbers.
What is the certificate of medical necessity (CMN)?
What is the certificate of medical necessity (CMN)?
What does orthotics deal with?
What does orthotics deal with?
Where are DMEPOS claims submitted?
Where are DMEPOS claims submitted?
What issues did HCPCS level II aim to resolve after its introduction in 1983?
What issues did HCPCS level II aim to resolve after its introduction in 1983?
Does HCPCS level II guarantee coverage for procedures, products, and services?
Does HCPCS level II guarantee coverage for procedures, products, and services?
What are the four types of HCPCS level II codes?
What are the four types of HCPCS level II codes?
What kind of language does HCPCS provide for health care providers and suppliers?
What kind of language does HCPCS provide for health care providers and suppliers?
Who develops and maintains HCPCS level II codes?
Who develops and maintains HCPCS level II codes?
When are permanent national codes updated?
When are permanent national codes updated?
Can HCPCS level II modifiers be used with any HCPCS level I or II code?
Can HCPCS level II modifiers be used with any HCPCS level I or II code?
What does the CPT coding system not describe?
What does the CPT coding system not describe?
What does prosthetics deal with?
What does prosthetics deal with?
Which HCPCS level II codes allow suppliers to begin billing immediately for a service or item?
Which HCPCS level II codes allow suppliers to begin billing immediately for a service or item?
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Study Notes
HCPCS Level II Coding Purpose
- HCPCS Level II codes are designed for uniform reporting of medical products and services on claims.
- DME (Durable Medical Equipment) includes items like canes, crutches, walkers, and commode chairs, supplied by DMEPOS dealers.
- DMEPOS encompasses a range of items such as artificial limbs, braces, medications, surgical dressings, and wheelchairs.
Code Development and Maintenance
- The CMS HCPCS workgroup is responsible for developing and maintaining HCPCS Level II codes.
- DME is defined by Medicare as equipment capable of withstanding repeated use.
Modifiers and Code Types
- Modifiers enhance any HCPCS code to clarify services and procedures performed by healthcare providers.
- Permanent codes are utilized by all private and public health insurers, ensuring consistent billing.
- Transitional pass-through payments are made as additional payments beyond the OPPS (Outpatient Prospective Payment System) payment.
Temporary and Miscellaneous Codes
- Temporary codes allow payers to establish new codes as required before the annual January 1 update.
- Miscellaneous codes are reported when no existing HCPCS Level II code applies.
Claims Processing
- CMS reduced fraudulent claims by processing all DME claims through only four DME MACs (Durable Medical Equipment Medicare Administrative Contractors).
- Providers and DMEPOS dealers access annual lists of valid HCPCS Level II codes, which include billing instructions.
- A signed certificate of medical necessity is required for certain items or services provided to patients.
Claims Submission
- For a Medicare patient treated for a fractured femur and given crutches, two separate claims are submitted—one to the MAC for the physician’s services and another to the DME MAC for equipment.
- The specific HCPCS Level II code determines the claim processing route, whether to the MAC handling provider claims or the DME MAC.
Code Structure and Updates
- HCPCS Level II codes consist of five characters, starting with letters A through V, followed by four numbers.
- The certificate of medical necessity acts as a physician's prescription for DME and related services and supplies.
Specialized Fields
- Orthotics involves the design and fitting of devices for musculoskeletal disorders.
- Prosthetics focuses on the design, production, and usage of artificial body parts.
HCPCS and Coverage
- HCPCS Level II was introduced in 1983 to streamline over 100 different coding systems, which complicated claims data analysis.
- HCPCS codes do not guarantee coverage or payment as they are not a reimbursement methodology.
Annual Updates and Code Types
- Permanent national codes are updated annually on January 1.
- HCPCS Level II modifiers can be appended to any HCPCS Level I or II code.
- HCPCS provides a standardized language for reporting professional services, procedures, supplies, and equipment.
Conclusion
- HCPCS Level II coding essential for claims processing related to DMEPOS, ensuring consistency and adherence to billing regulations.
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