Which temporary codes are reported to all payers

Prior to the advent of procedure coding, providers submitted written descriptions of the services they performed to payers for reimbursement. This proved inefficient, in that providers could report the same service with different descriptions. By this time, the government had become a major payer of healthcare services. While it too needed to standardize healthcare claims, it also bore the responsibility of controlling costs for taxpayers.

But standardization in medical reporting was not yet achieved. Figure 1: Development of procedure coding systems. For example, codes beginning with the letter J—used to report non-orally administered medication and chemotherapy drugs—are called J codes. A HCPCS code is then added to the claim when required by the payer to report products that may have been prescribed, injected, or otherwise delivered to the patient during the service.

In general terms—with some exceptions—medical coders use the three code sets when submitting medical claims to report the following:. For example, if a urologist diagnoses a patient with bladder cancer and performs a bladder instillation of 1 mg of Bacillus Calmette-Guerin BCG to treat the tumor, the medical coder might assign:. The medical coder must verify coverage with the payer prior to submitting a claim. Several third-party payers follow Medicare guidelines, but you must check with your payer.

Screening procedures are not diagnostic procedures. You might submit HCPCS code G Colorectal cancer screening; barium enema when an asymptomatic patient fits the once every year interval. If you bill G earlier than the year period, your claim will likely be denied. So, if you're filing a claim for a patient who was prescribed and received a new wheelchair, you might report HCPCS code E Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests and append NU, as in ENU, which would significantly affect reimbursement.

If your provider administers 44 units of Botulinum toxin injection by direct laryngoscopy from a unit single-dose vial, and then had to discard the remaining contents of the vial, you could report the discarded drug with the HCPCS JW modifier.

On the second line you would report JJW x 56 to identify the amount discarded. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures.

Note that while CPT codes have five digits, there are not 99,plus codes. Like the ICD code set and its division into chapters by type of injury or illness, Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:. CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are through In the CPT codebook, these codes are listed in mostly numerical order, except for the codes for Evaluation and Management.

Note also that some codes appear out of numerical sequence but near similar procedures. This may seems slightly confusing, but having these codes clustered near similar procedures prevents having to delete and resequence codes, and so is seen as a sort of necessary evil.

Within each of these code fields, there are subfields that correspond to how that topic—say, Anesthesia—applies to a particular field of healthcare.

For instance, the Surgery section, which is by far the largest, is organized by what part of the human body the surgery would be performed on. Likewise, the Radiology section is organized into sections on diagnostic ultrasound, bone and joint studies, radiation oncology, and other fields.

Please refer to the eBook for a complete breakdown of the subfields used in each of the code fields. Each of these fields has its own particular guidelines when it comes to use. For example, the Surgery section has a guideline for how to report extra materials used such as sterile trays or drugs and how to report follow-up care in the case of surgical procedures. If a procedure is indented below another code, the indented procedure is an important or noteworthy variation on the above procedure, and would replace the first code.

The first, which comes before the semicolon, is the general procedure. If we look in the CPT manual, we find the code below CPT codes also have a number of modifiers. These modifiers are two-digit additions to the CPT code that describe certain important facets of the procedure, like whether the procedure was bilateral or was one of multiple procedures performed at the same time. Finally, if a provider believes that any of the procedure or technology has been proven both safe and effective as well as reasonable and necessary, some insurers allow coverage on a case-by-case basis or may request coverage through a reconsideration process.

Check with the payer prior to providing the service to determine how to proceed. We want to hear from you! The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

What are Category III codes, and how are they best used for billing? January 31, Jonathan Rubenstein, MD Mark Painter Current Procedural Terminology codes provide a uniform language for reporting medical services and procedures provided by members of the medical community. Read: Biofeedback training code deleted, replaced with time-based codes It is imperative to check with your Medicare contractor and insurer guidelines to determine if a procedure, no matter which category, is a covered benefit.

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