HCPCS/CPT® Status Codes

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.

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.

Code deleted for this calendar year.

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.

Special cost payment identifier for cornea (eye) tissue obtaining only.

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)

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.

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.

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.

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.

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".

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.

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.

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.