Common Procedure Coding System

J Codes

“J Codes are the Healthcare Common Procedure Coding System (HCPCS) codes for the injection of drugs.[1]  “J Codes are drugs administered other than the oral method, chemotherapy drugs.[2] “The HCPCS “J” codes include the majority of those drugs and biologicals that should be reported with infusions, injections, and supply codes that go hand in hand with CPT procedure based coding.[3] A subset of the HCPCS Level II code set with a high-order value of “J” that has been used to identify certain drugs and other items.”[4]  For example: Herceptin has J9355, Privigen has J1459, Epogen has J1459, Epogen has J0885 and Humira has J0135. We have confirmed with one of the members of the CMS Work Group that J Codes also cover compound drugs.

Miscellaneous Codes

“ 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 maybe assigned by insurers for use during the period of time a request for a new code is being considered under the HCPCS review process.[5]”

“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.”[6]

Level II HCPCS used in billing under the Hospital Outpatient Prospective Payment System (OPPS)

.           “The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services (CMS) have joined together in establishing the AHA clearinghouse to handle coding questions on established HCPCS usage. The American Health Information Management (AHIMA) also provides input through the Editorial Advisory Board.  The AHA’s Central Office will handle the clearinghouse functions and provide open access to any person or organization that has questions regarding a subset of HCPCS coding, particularly hospitals and other health professionals who bill under the hospital outpatient prospective payment system (OPPS).  Specifically, the AHA’s Central Office will handle clearinghouse functions such as providing interpretation, promotion and explanation of the proper use of a subset of HCPCS codes as follows: Level 1 HCPCS (CPT-4 Codes) for hospital providers, Level II HCPCS Codes for hospitals, physicians, and other professionals who bill Medicare for A-Codes, C-codes, G-codes, J-codes and Q-codes (other than Q0163 and Q0181)” ^[7].

Updates

“The AMA updates and republishes CPT-4 annually and provides CMS with the updated data. The CMS updates the alpha-numeric (Level II) portion of HCPCS and incorporates the updated AMA material to create the HCPCS code file. The CMS provides the file to A/B MACs (A), (B), (HHH), and DME MACs and Medicaid State agencies annually.[8]” “The HCPCS are updated annually to reflect changes in medicine and provision of health care.”

The CMS provides a file containing the updated HCPCS codes to A/B MACS [Medicare Administrative Contractors for Parts A and B] (A), (B), HHH [Home, Health, and Hospice] and DME MACs [Durable Medical Equipment Medicare Administrative Contractors ] and Medicaid State Agencies 60-90 days in advance of the  implementation of the annual date. Distribution consists of an electronic file of the updated HCPCS codes, file characteristics, record layout, and a listing of changed and deleted codes. MACs are required to update their HCPCS codes file and map all new or deleted codes to appropriate payment information no later than three months after receipt of the update.”  There is a 2016 HCPCS Alpha-Numeric Index of 46 pages, which contains many drug products.

“Both the DME MACs and the A/B MACs (B) publish this list to educate providers on which MAC they should bill for codes provided on this list.[9]” “MACs will no longer accept discontinued HCPCS codes for dates of service January 1 through March 31.[10]

“In addition to the major annual update, CMS also updates HCPCS codes quarterly to reflect additional changes or corrections that are emergency in nature. Quarterly changes are issued by letter or memorandum for local implementation.[11]

“Physicians and suppliers must use HCPCS codes on the Form CMS-1500 or its electronic equivalent and providers must use HCPCS codes on the Form CMS-1450 or its electronic equivalent for most outpatient services.[12]” A/B MACs (B) and DME MACs must continue to reject services submitted with discontinued HCPCS codes. A/B MACs (A) and (HHH) must continue to return to the provider (RTP) claims containing deleted codes.[13]

“It is important for physicians, practitioners, suppliers, and providers to note that code/modifier recognition does not imply that a service is covered by Medicare.[14]” HCPCS is a system for identifying items and certain 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.”[15]

Currently, there are national HCPCS codes representing approximately 6,000 separate categories of like items or services that encompass millions of products from different manufacturers. When submitting claims, suppliers are required to use one of these codes to identify the items they are billing. The descriptor that is assigned to a code represents the definition of the items and services that can be billed using that code.”[16]

[1] Veterans Administration Hospital, J Codes Over Billing Schemes, Chief Business Office Purchase Care, Department of Program Integrity (DPI), October 2013.

[2] HCPro website, Note similarities between HCPCS, CPT Codes, September 5, 2012.

[3] HCPro website, Note similarities between HCPCS, CPT Codes, September 5, 2012.

[4] AAPC website.

[5] Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures, November 13, 2015.

[6] Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures, November 13, 2015.

[7] Medicare, HCPCS, General Information, HCPCS Coding Questions, Do you have a Coding Question.

[8] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015.

[9] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[10] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[11] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[12] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[13] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[14] Medicare Processing Manual, Chapter 23-Fee Administration and Coding Requirements, revisions 8-7-15, 10-9-2015, 11-23-2015

[15] Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.

[16] Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.