In the United States, health care providers submit billions of claims to insurers annually. To handle this massive volume efficiently and consistently, standardized coding systems are indispensable. The Health Care Common Procedure Coding System (HCPCS) is one such critical system, designed to ensure orderly and consistent processing of claims by Medicare and other health insurance programs. HCPCS is structured into two primary subsystems: Level I and Level II.
Decoding HCPCS Level I: CPT® Codes
HCPCS Level I is based on the Current Procedural Terminology (CPT®), a numeric coding system managed by the American Medical Association (AMA).
- CPT® provides a uniform language for coding medical services and procedures. It uses descriptive terms and unique identifying codes. These codes are primarily used by physicians and other healthcare professionals when billing public and private health insurance for their services.
- The AMA is responsible for the regular updates and publications of CPT® codes, ensuring they remain current with evolving medical practices.
- CPT® codes are composed of five numeric digits, offering a detailed classification of medical procedures.
- For specific inquiries or issues related to the application of HCPCS Level I CPT® codes by physicians, the AMA is the primary point of contact. You can reach out to them through their contact form.
Exploring HCPCS Level II: National Codes
HCPCS Level II is a distinct standardized coding system designed to identify products, supplies, and services not covered by CPT® codes. This includes a broad range of items such as ambulance services, durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS), particularly when used outside of a physician’s office setting.
- Many services, supplies, and equipment covered by Medicare and other insurers fall outside the scope of CPT® codes. HCPCS Level II codes were developed to enable providers and suppliers to accurately bill for these items.
- HCPCS Level II codes are alphanumeric, consisting of a single alphabetical letter followed by four numeric digits. This structure differentiates them from the numeric-only CPT® codes.
- The Centers for Medicare & Medicaid Services (CMS) is the authoritative body that maintains HCPCS Level II codes. CMS manages all aspects of these codes, including additions, revisions, and deletions, to reflect changes in healthcare services and supplies.
- The HCPCS Level II system originated in the 1980s, responding to the growing need for coding items beyond physician procedures.
- In 2003, the authority to establish and maintain uniform national definitions for services, the codes representing these services, and payment modifiers was officially delegated to CMS by the HHS Secretary, as outlined in 42 CFR 414.40(a). This formalized CMS’s role in governing HCPCS Level II codes.
- For any questions or clarifications regarding HCPCS Level II codes, you can contact the CMS directly at [email protected].
Utilizing MEARIS™ for HCPCS Level II Code Applications
The Medicare Electronic Application Request Information System (MEARIS™) serves as the online portal for submitting HCPCS Level II coding applications.
- Anyone has the right to propose modifications to the HCPCS Level II national code set, ensuring the system remains responsive to industry needs and innovations.
- The MEARIS™ platform is specifically designed for electronic submissions of HCPCS Level II applications, streamlining the process for:
- Quarterly applications for drug and biological products.
- Biannual applications for non-drug and non-biological items and services.
- Key application deadlines to note are:
- For drug and biological products: The first business day of each quarter (January, April, July, and October).
- For non-drug and non-biological items and services: The first business day of January and July.
Staying Updated with HCPCS Level II Coding Decisions
Recent Updates in HCPCS Level II Coding (October – December 2024)
On January 10, 2025, CMS released the coding decisions for the fourth quarter of 2024 HCPCS Level II drug and biological applications.
The detailed Healthcare Common Procedure Coding System (HCPCS) Application Summaries and Coding Decisions for quarter four (Q4) 2024 Drugs and Biologicals are available on the CMS website: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/Prior-Years-CMS-HCPCS-LevelII-Coding-Decisions-Narrative-Summary.
This document offers a summary of each Q4 2024 HCPCS Level II application for drug and biological coding requests, including:
- The specific topic or issue addressed in the application.
- A concise summary of the applicant’s request for coding consideration.
- CMS’s official coding decision for each application.
For the upcoming HCPCS updates, please monitor the CMS website for the April 2025 HCPCS Update file, which will be published separately at: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.
To access previous announcements and updates, please visit the HCPCS Level II Archive.
Keep Informed with Email Updates
Stay ahead with the latest information on HCPCS Level II codes by subscribing to the official HCPCS Level II Updates Listserv. It’s a quick and straightforward way to receive the most current and accurate updates directly from CMS.
