Dedicated to Lymphedema Patients and the Therapists Who Treat Them
HCPCS Level II Coding
Each year, in the United States, health care insurers process over 5 billion claims for payment. For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The HCPCS Level II Code Set is one of the standard code sets used for this purpose. The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS.
Level I of the HCPCS is composed of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items. The development and use of level II of the HCPCS began in the 1980's. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.
HCPCS is a system for identifying items and services. It is not a methodology or system for making coverage or payment determinations, and the existence of a code does not, of itself, determine coverage or non-coverage for an item or service. While these codes are used for billing purposes, decisions regarding the addition, deletion, or revision of HCPCS codes are made independent of the process for making determinations regarding coverage and payment. The coding system is not a methodology for making coverage or payment determinations. Each payer makes determinations on coverage and payment outside this coding process.
National codes also include "miscellaneous/not otherwise classified" codes. These codes are used when a supplier is submitting a bill for an item or service and there is no existing national code that adequately describes the item or service being billed. The importance of miscellaneous codes is that they allow suppliers to begin billing immediately for a service or item as soon as it is allowed to be marketed by the Food and Drug Administration (FDA) even though there is no distinct code that describes the service or item. A miscellaneous code can be used during the period of time a request for a new code is being considered under the HCPCS review process.
The use of miscellaneous codes also helps us to avoid the inefficiency and administrative burden of assigning distinct codes for items or services that are rarely furnished or for which we expect to receive few claims.
Because of miscellaneous codes, the absence of a specific code for a distinct category of products does not affect a supplier's ability to submit claims to private or public insurers and does not affect patient access to products. Claims with miscellaneous codes are manually reviewed, the item or service being billed must be clearly described, and pricing information must be provided along with documentation to explain why the item or service is needed by the beneficiary.
Application to Lymphedema Garments
In theory, lymphedema compression garment systems, compression garments and compression devices are coverable as Prosthetic Devices under Medicare (Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15, Section 120), In practice, they are denied as uncovered. Part of the process of making a claim that can be disputed is the assignment of a HCPCS Code describing the item. Furthermore, the code selected must be one that the Medicare Contractor's computer must accept into the system.
|The following codes have been used for insurance billing of lymphedema garments:|
|A4465||Non-elastic binder for extremity (Reid Sleeve)|
|A6531||Graduated Compression Stockings, Below Knee, 30-40 mmHg|
|A6532||Graduated Compression Stockings, Below Knee, 40-50 mmHg|
|A6542||Gradient Compression Stocking, Custom Made|
|A6543||Gradient Compression Stocking, Lymphedema|
|A6545||Grad. Compr. Wrap, Non-Elastic, Below Knee, 30-50mmHg (CircAid)|
|A6549||Gradient Compression Stocking/Sleeve Not Otherwise Specified|
|E0676||Intermittent Limb Compression Device (Includes all Accessories) NOS|
|E1399||DME NOS (Reid Sleeve, CircAid, Farrow Wrap, Jobst Sleeve)|
|L2999||Lower Extremity Garment|
|L3912||Flex Glove w/ elastic finger|
|L3999||Gauntlet with Fingers, Upper Extremity Garment|
|L7499||Upper Extremity Prosthesis Not Otherwise Specified|
|L8239||Gradient Compression Stocking NOS, (Arm Sleeve w/ Shoulder Strap)|
|L8499||Unlisted Procedure for Miscellaneous Prosthetic Services|
|L9900||Orthotic and Prosthetic Supply, Accessory and/or Service Component|
|Special HCPCS Medicare Non-Covered Insurance Codes|
|S8420||Gradient pressure aid (sleeve and glove combination), custom made|
|S8421||Gradient pressure aid (sleeve and glove combination), ready made|
|S8422||Gradient pressure aid (sleeve), custom made, medium weight|
|S8423||Gradient pressure aid (sleeve), custom made, heavy weight|
|S8424||Gradient pressure aid (sleeve), ready made|
|S8425||Gradient pressure aid (glove), custom made, medium weight|
|S8426||Gradient pressure aid (glove), custom made, heavy weight|
|S8427||Gradient pressure aid (glove), ready made|
|S8428||Gradient pressure aid (gauntlet), ready made|
|S8429||Gradient pressure exterior wrap|
|S8430||Padding for compression bandage, roll|
|S8431||Compression bandage, roll|
|HCPCS Codes for Intermittent Compression Devices and Pneumatic Garments|
|E0650||Pneumatic compressor, non-segmental home model|
|E0651||Pneumatic compressor, segmental home model without calibrated gradient pressure|
|E0652||Pneumatic compressor, segmental home model with calibrated gradient pressure|
|E0655||Non-segmental pneumatic appliance for use with pneumatic compressor, half arm|
|E0656||Segmental pneumatic appliance for use with pneumatic compressor, trunk|
|E0657||Segmental pneumatic appliance for use with pneumatic compressor, chest|
|E0660||Non-segmental pneumatic appliance for use with pneumatic compressor, full leg|
|E0665||Non-segmental pneumatic appliance for use with pneumatic compressor, full arm|
|E0666||Non-segmental pneumatic appliance for use with pneumatic compressor, half leg|
|E0667||Segmental pneumatic appliance for use with pneumatic compressor, full leg|
|E0668||Segmental pneumatic appliance for use with pneumatic compressor, full arm|
|E0669||Segmental pneumatic appliance for use with pneumatic compressor, half leg|
|E0670||Segm. Pneu. Appl. for use with pneumatic compressor, integrated, 2 full legs and trunk|
|E0671||Segmental gradient pressure pneumatic appliance, full leg|
|E0672||Segmental gradient pressure pneumatic appliance, full arm|
|E0673||Segmental gradient pressure pneumatic appliance, half leg|
|E0675||Pneu. Compr. device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)|
|E0676||Intermittent limb compression device (includes all accessories), not otherwise specified|