No HCPCS Code Available? Now What?

February 21st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Billing   HCPCS Coding   Medicare  
0 Votes - Sign in to vote or comment.

HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes.

There are several types of HCPCS level II codes such as:

  • Permanent National Codes
  • Dental Codes
  • Miscellaneous Codes
  • Temporary National Codes

Most products and procedures have a code assigned; in fact, there are approximately 6,000 separate categories of items or services that include millions of products from different manufacturers.  However, when there is not a HCPCS code that accurately describes a particular service or product you are required to use a miscellaneous or not otherwise classified code.

In fact, there are many occasions you will find you need to use an unlisted HCPCS code, for example, if it is a new product or there has not been an application submitted to CMS to assign a new code. Using the unlisted, miscellaneous or unclassified drug code(s) require more information submitted on your claim form with additional attention and details when billing. 

New supplies or drugs are often left with an unspecified or unclassified code. Suppliers frequently contact us for a billing code on a new product when there is not a specific HCPCS code that fits the supply or drug they need to bill for, hoping to eliminate the need for the additional information to be reported on the claim form.   

For example for submitting a claim for an unlisted drug, you need to supply the payer with:

Name, strength, and dosage.   

Some Payers require different information, for example, United Healthcare requires the NDC number, quantity and the unit of measure when billing unlisted drugs. This required information on your claim should be submitted in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in the ANSI 837 claim file).

Before you give up your search for an appropriate HCPCS code and decide to use the unlisted or unclassified codes be sure to check out the DMEPOS Product search tool Find-A-Code offers.  This tool will allow you to search the product name, manufacturer name or model number giving you information that is not found with any other tool. This tool may help you avoid a claim denial due to an incorrect code, claims will be denied if there is a more specific code available and a non-specific code is billed. 

If there is not a specific HCPCS code contact the labeler or vendor to see if they have applied for a HCPCS code for their product, it may have already been requested and may be pending or if CMS HCPCS workgroup is considering a coding request. If you would like to request or suggest a revision or apply for a permanent HCPCS code you can contact CMS. 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
April 12th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
April 12th, 2021 - Wyn Staheli, Director of Research
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
Properly Reporting Imaging Overreads (Including X-Rays)
April 8th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
March 31st, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
Understanding Skin Biopsy Codes
March 23rd, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...
How Reporting E/M Based on Time May Lose Money
March 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
COVID-19 Vaccines
March 10th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
To accommodate the new COVID-19 immunizations the CPT editorial panel has approved 11 Category I codes. Watch for new and revised guidelines and parenthetical notes with these codes. For example; which administration codes should be used with the vaccine codes and the NCD codes applicable to the dose being administered. These ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association