HCPCS
align=center>In the first two parts of this series, I presented the more common aspects of procedural coding, the use of CPT codes to describe what you did and the use of ICD-9 codes to describe what you found. In this article I will describe another coding system, designed to complement CPT codes.
HCPCS (HCFA Common Procedural Coding System) is a series of codes developed by the federal government and specifically the Center for Medicare and Medicaid Services (CMS) (formerly known as the Health Care Finance Administration (HCFA)). CMS uses these codes primarily for Medicare and Medicaid to describe procedures or items not listed in the CPT manual.
'What is the difference between CPT codes and HCPCS?'
CPT codes are owned and copyrighted by the American Medical Association. They describe common procedures used in the course of health care delivery and are oriented to physician use in one way or another. HCPCS are codes generated by the federal government to describe procedures that have special significance to either the Medicaid or Medicare programs.
There is some overlap between CPT codes and HCPCS. This is because level 1 HCPCS codes are, in fact, CPT codes. Level 2 HCPCS codes are unique codes that, for us, begin with a 'V' or a 'W'. There also exists a level 3 series of codes that I will address below.
If the procedure is used in the course of providing medical diagnostics or treatment to a Medicare or Medicaid patient, then a CPT code is used to describe what was done. If what was done to and for the patient goes beyond diagnostics and treatment and into the realm of therapeutic intervention, then a level 2 HCPCS code is often chosen to describe what was done.
As a case in point, the code V5010 describes a diagnostic audiological evaluation (similar to 92557). But V5010 also has a specific connotation of an evaluation that was performed for the primary purpose of selecting appropriate hearing aid amplification. Hence, if a patient were seen for a hearing evaluation to support an otolaryngology visit in the process of diagnosing hearing loss, then the audiologist would use the CPT code 92557. In contrast, if the patient were seen for the primary purpose of obtaining an audiogram for hearing aid selection, then the code V5010 would be appropriate. As a word of caution, there is sufficient overlap between the two codes that both 92557 and V5010 should not be used for the same visit. That may constitute double billing and cause difficulties down the road (i.e., audit).
There are other codes that are commonly used for audiological procedures for which no CPT codes exist or are generally not reimbursable by most third party payers. Examples include V5090 (hearing aid evaluation and fitting, monaural), V5110 (hearing aid evaluation and fitting, binaural), and V5900 (earmold). In the case of V5090, there is a corresponding CPT code (92590). But most commercial third party payers do not recognize this CPT code as a procedure eligible for reimbursement. For the other two examples, the CPT code 92599 (unlisted otolaryngological service or procedure) would be the only option. Obtaining reimbursement under 92599 is extremely challenging, at best! In general, the 'V' codes are used only with Medicare and Medicaid patients, and typically only Medicaid patients, since Medicare does not reimburse for any procedures related to hearing aids.
Each state is different with regard to which codes are allowed for use by audiologists versus physicians. For example, one state may permit the use of 92557 for audiological evaluations such as annual hearing rechecks and V5010 for audiograms specifically oriented toward hearing aid fitting. Other states require the use of V5010 for all diagnostic audiological procedures and deny access to 92557 for use by audiologists.
The determination of which codes are accessible to audiologists depends on three factors: the authorization of hearing services by the legislature of that state and the dollar allocation allotted to support Medicaid services; budget neutrality issues for statewide Medicaid services; and the willingness of Medicaid consultants and staff at the state level to allow access to additional codes.
For each of these factors, audiologists must remember that Hearing Services under Medicaid are optional services. If a state legislature so chooses, federal guidelines permit the elimination of Hearing Services for adults, children, or both. Additionally, the scope of services within the Hearing Services category is optional and may vary from one state to another.
If a new code is authorized and the state is under a 'budget neutrality' guideline, the value of the older codes may be reduced slightly to reflect both the availability and quantity of use of the new code. As a result, 'more' is not always 'better' with regard to reimbursement!
As an additional reminder, the 'V' codes used in the HCPCS listings should not be confused with the 'V' codes, which are part of the ICD-9 series of codes. The difference between the two 'V' code sets is that the ICD-9 'V' codes describe hearing procedures unrelated to the primary purpose of a patient's office visit. For example, if a patient arrives at a physician's office for a blood pressure check, and, while there, asks to have his hearing tested, the hearing test would be considered 'unrelated' and therefore, not medically necessary. The corresponding code would be V72.1. In contrast, the 'V' codes on the Medicare and Medicaid lists are for medically necessary procedures to be coded specifically for Medicare or Medicaid.
Using these codes appropriately can be a daunting task. If ever a question exists about which code to use for the respective payers, the best advice is to call the provider services representative for that payer and ask! Additionally, I certainly recommend that the audiologist document the name and phone number of the provider services representative, and also document the time and date of the call in case a procedural issue is contested at a later date.
