HCPCS/CPT® Status Codes
HCPCS status codes are important because they indicate important information
concerning billing, payment, and reimbursement for a particular CPT® or
HCPCS code.
Every CPT® or HCPCS code that is currently active will have a status
indicator assigned to it under OP PPS whether it is paid by Medicare or
not.
The status letters and meanings can be changed by Medicare at any time
but generally do
not change more than once a year when the APC rate changes are published.
The current list and status definitions can be found in the Federal Register
publication that outlines the current year APC changes. The status list
definitions along with the HCPCS-Status crosswalk are found in separate
appendices.
You can view a charge's HCPCS/CPT® Status Indicator on the Active Info window.
Current Status Codes and Meanings:
Status
A — Payment by a non-APC group payment methodology
This status group identifies supplies or services paid by non-APC methods
such as fee Schedules. There are several different types of payment within
this grouping:
A — DMEPOS or Durable Medical
Equipment/Prosthetic/Orthotic fee schedule
DME codes can't be billed on a UB-92 to the FI but must be billed on
a 1500 bill form to a regional DME carrier for payment. These supplies
will have a suggested Revenue code in the 29x series.
A special and separate provider number must be applied for by the Hospital
as they are functioning as an equipment supplier.
Some of the prosthetics and orthotics are billed on the UB-92 to the
hospital's FI and some have to be billed on a 1500 bill type to the DME
carrier.
B — Rehab Fee Schedule
Services
that fall under this fee schedule are CPT® codes for services of physical,
occupational, audiology and speech therapists.
C — Ambulance Fee Schedule
All HCPCS ambulance codes starting with an "A". Codes require
special modifiers indicating type of transport, origination and destination
sites. Info provided in modifier module.
D — EPO Payment for End Stage
Renal Patients on Dialysis
Special type of payment for particular dialysis
patients' injections.
E — Lab Fee Schedule
All diagnostic lab services not paid under APC rates and eligible for
outpatient payment. Does not include some pathology services which may
still paid by cost reimbursement methodology.
F — Screening Mammography
Payment Rates
These are in a class all their own and the Payment is subject to adjustment
once a year. The schedule only applies to screening.
G — Pulmonary Rehab Clinical
Trial Payment
This is a special program for which Hospitals must qualify.
Status
C — Inpatient Procedures
This status indicator
is very important on an outpatient bill type because presence of a "C"
status code on an outpatient bill type will cause a total claim reject.
A "C" status
means payment will only be made on an inpatient basis. In other words.
The patient must have been admitted and the bill type must be an inpatient
bill.
Most facilities want
to know what these CPT®/HCPCS codes are. Generally, if they do appear
on an outpatient bill the service has been miscoded.
Status D — Deleted Code
Code deleted for this calendar year.
Status
E — Non-Covered Item or Service
Medicare never pays
for this item or service. Not to be confused with bundled service or item.
Generally, the services are preventive or experimental in nature.
These services or items
should not be billed to the Medicare program unless the Patient specifically
requests a denial notice from Medicare to submit to a Secondary insurance.
In that event special value or condition codes are required on the bill
and record must document the patient's request.
Billing of these services
without a patient request is considered fraudulent, i.e. an attempt to
double dip for payment.
Status
F — Acquisition of Cornea Tissue
Special cost payment identifier for cornea (eye) tissue obtaining only.
Status
G — Pass-Through Payment for Drugs and Biologics
This is your pass through
identifier for drugs and biologics such as radiology contrast solutions.
Separate payment is
made for these as well as payment for the visit or procedure.
Payment for these could
be in the form of a defined APC payment rate or based on average wholesale
drug costs which are adjusted by the hospitals cost to charge ratio (%
defined by Medicare - specific to the Hospital - driven by the Information
submitted on their last reconciled cost report)
Status
H — Eligible for Device Pass Through Payment
This is the pass through
identifier for additional payment for certain identified devices such
as catheters, stents, pacemakers and leads, and neurostimulators which
now are reported with device category codes ("C" codes).
The limited (about 90)
category codes replaced the extensive (>600) specific Brand Name or
Manufacturer type "C" codes.
Medicare has very specific
published criteria that must be met for any device reported using the
category codes since the use of such codes results in additional payment
under OP PPS.
Status
K — Non Pass Through Drug/Biological
These products are also paid for separately
in addition to a procedure APC but are not classified as pass-throughs.
All of the vaccine products (rabies, diptheria, flu) fall under this category.
Status N — Incidental, Packaged
Services
There is no additional
payment for these services or products. Medicare considers the payment
to have been made when the procedure or visit APC payment is made.
Medicare recommends
that hospitals report these services on the bill, even though they are
not separately paid since their associated costs are considered when determining
revisions to associated APC payment rates.
Status P — Partial Hospitalization
Partial hospitalization
includes various psychiatry services performed as outpatients in a special
program called "Partial Hospitalization". The CPT®/HCPCS codes
are exactly the same service/codes that can be provided in an outpatient
psych or other clinic but the difference is special program requirements
and additional value codes that must go on the outpatient bill in fields
other than the CPT® code or Revenue code fields.
There are also a few
codes such as G0177 that will only be paid for if provided in a partial
hospitalization program.
Status S — Significant Procedure,
Not Discounted
These are considered major outpatient procedures that are always paid
100% of the APC rate even if performed with other services. They are often
thought of as being surgical in nature but many of the radiology diagnostic
exams have a status of "S".
Status
T — Significant Procedure, Multiple Surgery Discount applies
These procedures when
performed alone or in conjunction with a medical visit code (99201 - 99215,
99281 - 99285) or ancillary service such as lab, are paid at 100% of the
APC rate.
If however, the procedure
is done at the same session as a procedure with status "S" it
will only be paid at 50% of the APC rate.
If the procedure is
done at the same session as a procedure that also has a status of "T",
the first service will be paid at 100% and the 2nd and subsequent "T"
status services will be paid at 50% of the APC rate. This, of course,
assumes that the services are allowed to be billed together and don't
fall under the CCI edits.
CCI edits is a cross
reference list published and updated by Medicare that says - if you bill
code 1 then you cannot bill codes 1 - X because they are inherently included
in code 1 from a clinical perspective. In other words, you can't do 1
without always doing the subsequent services. Therefore, you have already
been paid when we paid you for code 1.
Status V — Visit
This status identifies
services identified as medical visits. Typically they occur in clinics
and the emergency room. However, visit codes can also be used in areas
like chemotherapy, radiation therapy, and wound care areas that may not
be officially designated as clinics by the hospital.
There are distinctive
and separate CPT® code sets and payments for new patients versus follow
up or repeat patients.
Medicare has defined
rules for when it is allowed to bill for a procedure and a visit. If the
definition and medical record documentation support reporting both a special
modifier (25) is required to be reported on the visit code. This directive
is explained in our modifier module under modifier 25.
Status X — Ancillary Service
This category and description
is a little misleading because you might think it would refer to areas
like lab and cardiology, but this isn't the case.
This status could identify
a:
Service — chemotherapy administration
— "Q" codes
Product — blood products — "P"
codes
Drugs — chemo oral anti-emetics — "Q"
codes
Devices — Cochlear Implant Device
Not all services with a status of "X" are covered or paid
by the Medicare program.
Those that are will
be paid using an APC rate.
There are generally
very special coverage rules that apply and specific information that must
be documented in the medical record to get paid using status "X"
codes. For example, for oral anti-emetics to be covered they must be given
within a certain time of administering the chemo drug and all supporting
services (CPT® and Diagnosis codes) must be reported on the same bill
or payment will be denied.
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