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No HCPCS Code Available? Now What?

February 21st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Billing   HCPCS Coding   Medicare  
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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:

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. 

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