Navigating the landscape of healthcare can be complex, and a crucial aspect of this complexity lies in the systems used for coding and classification. These systems are the backbone of medical billing, data analysis, and public health tracking. While older systems like ICD-9 have paved the way, today’s standards are represented by comprehensive code sets like ICD-10 and HCPCS. This article provides an overview of these national healthcare coding standards, essential for anyone involved in the medical field, from healthcare providers to administrators.
ICD-10 Codes: Diagnoses and Procedures
ICD-10, the International Classification of Diseases, Tenth Revision, is a globally recognized system that provides codes for diagnoses and inpatient hospital procedures. The transition from ICD-9 to ICD-10 in October 2015 marked a significant advancement in healthcare coding. ICD-10 offers a much greater level of specificity and incorporates modern medical terminology and classifications, aligning better with current technology and clinical practices.
Within ICD-10, there are two distinct code sets:
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ICD-10 Procedure Coding System (ICD-10-PCS): This code set is specifically for inpatient hospital procedures. It is developed and maintained by the Centers for Medicare & Medicaid Services (CMS). ICD-10-PCS allows for detailed coding of procedures performed in hospitals, contributing to accurate data collection and billing.
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ICD-10 Clinical Modification (ICD-10-CM): Used across all healthcare settings by all providers, ICD-10-CM is designed for coding diagnoses. It is developed and maintained by the Centers for Disease Control & Prevention (CDC), specifically the National Center for Health Statistics (NCHS). ICD-10-CM is vital for documenting patient conditions and is used for everything from clinical documentation to epidemiological studies.
Proposals for ICD-10 Code Modifications
The ICD-10 Coordination and Maintenance Committee (C&M) plays a critical role in keeping the ICD-10 code sets current and relevant. This federal interdepartmental committee, with representatives from CMS and NCHS, is responsible for the routine maintenance, testing, enhancement, and expansion of ICD-10. The C&M Committee jointly approves coding changes, develops errata, addenda, and other modifications to reflect new medical procedures, technologies, and newly identified diseases.
Requesting ICD-10-PCS Modifications
For those seeking to modify ICD-10-PCS, suggestions can include proposals for new or revised procedure codes or requests for technical coding updates. This might involve enhancing existing procedure code concepts, such as adding new body part values or approach values. To propose an ICD-10-PCS procedure code modification, recommendations should be submitted three months prior to a scheduled committee meeting. Requests for new codes should clearly describe the proposed code and provide a rationale for its necessity.
CMS uses the MEARIS™ platform to manage ICD-10-PCS code request applications. All applications must be submitted through MEARIS. Once reviewed, requestors are informed whether their proposal has been approved for presentation at the ICD-10 Coordination and Maintenance Committee meeting. Detailed information about the ICD-10-PCS application process can be found in the CMS Process for Requesting New/Revised ICD-10-PCS Procedure Codes.
Requesting ICD-10-CM Modifications
The CDC’s National Center for Health Statistics (NCHS) takes the lead on ICD–10–CM diagnosis codes. For those interested in proposing changes or additions to ICD-10-CM, the NCHS ICD-10 Coordination and Maintenance Committee webpage provides comprehensive information on the process and submission guidelines.
HCPCS Codes: Expanding Beyond ICD-10
The Healthcare Common Procedure Coding System (HCPCS) is another essential national medical code set. It ensures that claims are processed consistently and in an organized manner. HCPCS is divided into two main levels: Level I and Level II.
HCPCS coding is important to note, is not a determinant of coverage or payment by Medicare. The presence of a code does not automatically guarantee Medicare coverage for a service or item.
HCPCS Level I: CPT® Codes
HCPCS Level I codes are based on the Current Procedural Terminology (CPT®) code set. CPT® codes are maintained by the CPT® Editorial Panel and are copyrighted by the American Medical Association (AMA). CPT®-4 is the current version of HCPCS Level I. These codes primarily identify medical, surgical, and diagnostic services and procedures. CPT®-4 codes are organized into six main sections:
- Evaluation and Management
- Anesthesiology
- Surgery
- Radiology
- Pathology and Laboratory
- Medicine
For information on revisions, updates, or modifications to the CPT® code set, refer to the CPT® process on the AMA website.
HCPCS Level II: National Codes
HCPCS Level II codes are national codes established and maintained by CMS. They are used primarily to identify products, supplies, and services not included in HCPCS Level I (CPT®) codes. This includes a wide range of items and services such as:
- Certain drugs and biologicals
- Ambulance services
- Durable medical equipment (DME)
- Prosthetics
- Orthotics
- Supplies (DMEPOS)
CMS has a standard application process for requesting HCPCS Level II codes. Detailed instructions and information can be found at CMS HCPCS General Information. The application portal is accessible through MEARIS.
Miscellaneous Codes in HCPCS Level II
HCPCS Level II also incorporates miscellaneous codes (unlisted, unclassified, NOS, or NOC codes). These are used when an existing code doesn’t adequately describe a service or item. While these codes allow for immediate billing for newly FDA-approved items or services pending specific code assignment, providers should always verify with their Medicare Administrative Contractors (MACs) to ensure a more specific code isn’t appropriate before using a miscellaneous code.
HCPCS Modifiers
Modifiers are crucial in HCPCS coding. They are appended to HCPCS codes to provide additional details about the service or item, which can affect payment or coverage conditions. For instance, the “UE” modifier indicates “used equipment,” and the “NU” modifier signifies “new equipment” for DME items.
More information on HCPCS Level II codes can be found at HCPCS Level II Coding Process. For pass-through payment codes, refer to MEARIS for Device Pass-Through and Drugs and Biological Pass-Through information. Pass-through payments offer temporary additional payments for certain new devices, drugs, and biologicals.
Other HCPCS Level II Code Types: C Codes and G/M Codes
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C codes: These are temporary HCPCS Level II codes created by CMS specifically for Medicare. They are used for new technology devices, drugs, biologicals, and radiopharmaceuticals that have received transitional pass-through status under the Medicare Hospital Outpatient Prospective Payment System (OPPS).
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G codes and M codes: These codes identify professional healthcare services and medical services that could be coded in CPT®-4 but for which CMS has established a Level II code. CMS typically establishes G codes through rulemaking to support Medicare policy and claims processing needs. Although created for Medicare, G codes can also be used by non-Medicare insurers.
HCPCS Level II codes are updated multiple times a year, with specific schedules for drugs/biologicals and DMEPOS/other items. Pass-through items have their own update schedule. Applications for HCPCS Level II codes can be submitted via MEARIS.
Beyond ICD-10 and HCPCS: Other Important Code Sets
While ICD-10 and HCPCS are central to national healthcare coding standards, other code sets play important roles:
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National Drug Code (NDC): Nearly all drugs in the U.S. have an NDC, maintained by the FDA. It uniquely identifies manufactured drugs. More information is available on the FDA’s website.
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Code on Dental Procedures and Nomenclature (CDT): CDT codes, maintained by the American Dental Association (ADA), are used for billing dental procedures and supplies.
Summary of Code Sets and Classifications
Understanding the different code sets and who maintains them is crucial for accurate healthcare coding and billing. Each system has its own application process and is intended to be mutually exclusive.
Code Set and Classification Summary
| Codes maintained and updated by CMS: | Codes maintained and updated by another agency/entity: |
|---|---|
| ICD-10-PCS Link for more information | ICD-10-CM Maintained and updated by NCHS and CDC Link for more information |
| HCPCS Level II Link to application | HCPCS Level I (CPT®-4) Maintained and updated by AMA Link to application |
| NDC Maintained and updated by the FDA Link to application | |
| CDT®-4 Maintained and updated by the ADA Link to application |
Accurate and compliant healthcare coding relies on understanding and correctly applying these national standards. Utilizing resources like MEARIS and staying updated on code set modifications are essential for healthcare professionals and organizations.
