HCPCS CODE MODIFICATION PROCESS-MEDICAID
Purpose
The purpose of these instructions is to provide a streamlined process
for requesting new codes or changes to existing Healthcare Common
Procedure Coding System (HCPCS) codes for services, products, or
items, not covered by Medicare, that are needed by state Medicaid
programs. These codes are classified as "T" codes for HCPCS
purposes. They may or may not be needed by private payers.
General Code Modification Process
The Healthcare Common Procedure Coding System contains alpha-numeric
codes used to identify those coding categories not included in the
American Medical Association's Current Procedural Terminology
(CPT-4) codes. Under the usual process, a HCPCS National Panel makes
decisions pertaining to additions, deletions and changes to the HCPCS.
This Panel, which meets three times a year, is comprised of
representatives of the Blue Cross/Blue Shield Association, the Health
Insurance Association of America and the Centers for Medicare and
Medicaid Services. The Centers for Medicare & Medicaid Services
(CMS) HCPCS Workgroup, comprised of representatives of the major CMS
components, meets approximately once each month to make CMS
recommendations to the National Panel pertaining to HCPCS codes. In
order to be considered for inclusion as a permanent code(s) in the
annual HCPCS update, the CMS HCPCS Workgroup must receive your
completed recommendation packet no later than April 1 of the previous
year.
Medicare Code Modification Process
Requests for new codes or changes to existing HCPCS codes for
services, products, or items that have implications for Medicare, and
requests that relate to durable medical equipment, prosthetics,
orthotics and supplies (DMEPOS), or drugs must be submitted by
following the procedures outlined at
http://www.hcfa.gov/medicare/hcpcs. If you have questions regarding
Medicare-related recommendations, you should contact C. Kaye Riley,
HCPCS Coordinator, by e-mail at HCPCS@cms.hhs.gov or by telephone
(410) 786-5323. If your recommendation relates to professional
services addressed by the CPT-4 code set, you should make your request
using the instructions provided on the internet at
http://www.ama-assn.org/ama/pub/category/3113.html.
Medicaid Code Modification Process
This process provides an alternative means for state Medicaid agencies
to meet their coding needs for services, products, or items which are
not represented in the current HCPCS codes and are not covered by
Medicare. It is particularly appropriate for states seeking national
HCPCS codes to replace local codes that will no longer be recognized
in health care transactions under provisions of the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, as modified by the
Administrative Simplification Compliance Act of 2001. States should
only request national HCPCS codes after first determining that current
codes do not identify the service, product, or item in question.
Under this process, the state Medicaid agency (or a group representing
state Medicaid agencies) submits its code request directly to
CMS's Center for Medicaid and State Operations (CMSO). Medicaid
program staff in CMSO initially reviews the request and provides
comments to the requester. The requester finalizes the request and
returns it (with 35 copies) to CMSO. The formal request is then
forwarded by CMSO to CMS HCPCS Workgroup staff. If clarification is
needed, the requester will be contacted and provided the opportunity
to make changes to its request or supply additional information.
Workgroup staff distribute your copies of the final submission to the
CMS HCPCS Workgroup. Your item and others are placed on an agenda for
review against current codes at a regularly scheduled meeting of the
Workgroup. Requests for temporary codes that are approved during the
regular CMS HCPCS Workgroup meeting are posted on the CMS HCPCS
website identified above. In some cases, further information will be
requested from the submitter based on Workgroup comments. Code
requests that have implications for private payers will be forwarded
to private payer representatives on the National Panel for their
review.
Guidelines for Submitting Medicaid Code Requests
When submitting your recommendation, identify one code or a group of
similar code requests per submission packet. Each requested code
should be labeled T???1, T???2, etc. Do not suggest specific
alpha-numeric codes for your individual code requests. The CMS HCPCS
Workgroup will assign alpha-numeric codes to those requests it
approves. In addition to providing the information requested below,
please include other descriptive material and printed materials which
you think would be helpful in furthering the CMS HCPCS Workgroup's
understanding of the nature of the service, product, or item and the
need for a new code or coding change.
Once you decide that a new code or coding change is needed to
accommodate a service, product, or item, you should provide CMSO
(i.e., David Greenberg) via e-mail with a draft recommendation for
review before submitting a formal request and additional copies. This
will enable CMSO and the requester to discuss changes that may enhance
the likelihood of a favorable decision on your request by the
Workgroup.
Once there is agreement regarding any changes to the draft
recommendation, you should submit an original final request and 35
complete copies of your submission for distribution to members of the
CMS HCPCS Workgroup. We request that each request (with supporting
information) be limited to 40 pages, and that you not submit requests
in 3 ring binders. The completed, signed and dated recommendation
request and supporting documentation should be bundled securely to
ensure that all the submitted information is distributed intact to all
reviewers. If the draft recommendation requires no or minimal changes,
CMSO may be able to forward, as the final submission, your draft
recommendation with an indication of the changes to which the
requester and CMSO have agreed.
Healthcare Common Procedure Coding System (HCPCS)
Alpha-Numeric Coding Recommendation Format
Instructions:
1. Please sign and date each recommendation. Be certain to provide the
name, address and telephone number of the person to be contacted
regarding this recommendation. Only state Medicaid agencies or groups
representing them can submit code requests under this process.
2. Please note: All requested information must be supplied before your
recommendation for modifications to the HCPCS coding system can be
considered. The following questions may be transferred to a word
processor/computer if additional space is needed to respond.
Incomplete submittals will be returned for clarification. Do not label
individual code requests with specific alpha-numeric codes. The CMS
HCPCS Workgroup will assign alpha-numeric codes to those requests it
approves.
4. Submit Coding Recommendations to:
J. David Greenberg
Centers for Medicare and Medicaid Services
S2-01-16
7500 Security Blvd
Baltimore, Maryland 21244-1850
Alpha-Numeric HCPCS Coding Recommendation Format
INFORMATION SUPPORTING CODING MODIFICATION
RECOMMENDATION
1. Name of service, product, or item:
2. Describe the service, product, or item in general terminology.
3. Define the justification (business need) for this service, product,
or item (e.g., change in technology, advance in science).
4. If this service, product, or item is required under Federal/State
Law, please provide the "effective date".
5. Why are current codes inadequate to describe the service, product,
or item?
6. Provide available information on which other states and payers
already cover this service, product, or item, how long they have
covered it, how many beneficiaries/patients receive it, how many
claims have been paid, and what the total expenditures have been for
the service, product, or item?
Recommendation submitted by:
Name:
Name of Organization:
Complete Mailing Address:
Telephone Number:
FAX Number:
E-Mail Address:
_________________________ Signature
__________________________ Date
Last Modified on Thursday, September 16, 2004
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