Chapter IV: Inquiries Submenu (01)
HCPCS Codes (14)
Purpose
The purpose of the HCPC CODES option is to provide access to details related to the HCPCS codes available to be reported on a claim.
HCPCS codes are five-digit alphanumeric Category II procedure codes developed by CMS to describe a medical service or supply. Category I codes are five-digit numeric CPT codes, developed and copyrighted by the American Medical Association. The HCPC CODES option includes details for both CPT codes and HCPCS codes.
Note: All HCPCS/CPT codes listed in the HCPC CODES option are FISS editing files. Claims submitted that do not correspond with the data contained within the HCPC CODES option will be RTPd.
To access the HCPC CODES option from the FISS online system INQUIRES submenu, type ‘14’ at the Enter Menu Selection: prompt, then press <Enter>.
To access HCPCS/CPT code data, type the Carrier ID in the CARRIER field and the Location ID in the LOC field.
- The provider’s Carrier ID and Location ID can be found in the ZIP CODE FILE option (19) in the Inquiries Submenu. Type ‘19’ in the SC field and press <Enter>. Type your ZIP Code to identify your Carrier ID and Location ID. Press the <F3/PF3> key to return to this inquiry screen.
Type the HCPCS/CPT code you wish to research in the HCPC field, then press <Enter>.
The HCPC INFORMATION INQUIRY screen is updated to provide the HCPCS/CPT code details. As an example, the results of an inquiry for CPT code 70010 is shown:
| Field | Description |
|---|---|
| CARRIER | Carrier number assigned to the provider (five-position alphanumeric field) |
| LOC | Locality code identifying the area (or county) where the provider is located (two-position alphanumeric field). Enter ‘Z1’ or ‘Z2’ in this field with a lab HCPCS. Press <Enter>. The Carrier field will display ‘LABCB’. To display the demo pates press the <PF11> key. |
| HCPCS | HCPCS/CPT code |
| MODIFIER | Identifies multiple fees for one HCPC code based on the presence or absence of a modifier in this field (two-position alphanumeric field) |
| IND | HCPCS Indicator Valid Values: A through Z with the exception of H, I, O, R, S ‑ ASP Price Bucket Indicator H ‑ Rural DME R ‑ RHHI Blank ‑ Default |
| EFF DATE | Effective date for this code |
| TERM DATE | Termination date for this code |
| PROVIDER | Medicare Provider number of alias provider |
| DRUG CODE | Identifies that the HCPCS is a drug and is present on the MMA drug-pricing file. This is a one-position alphanumeric field. Valid Values: E – HCPCS is drug Blank – HCPCS is not drug |
| EFF DATE | Identifies when the Change In Pricing went into effect (six-position numeric field in MMDDYY format with four occurrences) |
| TERM DATE | Identifies the Termination Date for each rate listed for this HCPCS/CPT code (six-position alphanumeric field in MMDDYY format with four occurrences) |
| EFF | Effective indicator – Instructs the system to either use the service dates on the claim or to use the system run date to perform edits for this particular HCPCS/CPT code. Valid Values: D = Discharge date (hemophilia clotting factors) F = Claim from date R = Claim receipt date |
| OVR | Override code ‑ Instructs the system in applying the services to the beneficiary’s deductible and coinsurance Valid Values: 0 = Apply deductible and coinsurance 1 = Do not apply deductible 2 = Do not apply coinsurance 3 = Do not apply deductible or coinsurance 4 = No need for total charges (used for multiple HCPCS for single revenue code centers) 5 = RHC or CORF psychiatric M = EGHP (may only be used on the 001 total line for MSP) N = Non-EGHP (may only be used on the 001 total line for MSP) X = MSP cost avoided Y = IRS/SSA data match project, MSP cost avoided |
| FEE | Fee indicator – This is an indicator received from CMS to show when a HCPCS code is to be paid at the Medicare physician fee schedule (MPFS) for therapy, audiology or CORF. Valid Values: R = Payment is made based on the MPFS B = Service is a bundled service. No separate payment is made Blank = Payment is not based on the MPFS |
| OPH | Outpatient hospital indicator Valid Values: 0 = MPFS applies to all outpatient bill types (12X, 13X, 22X, 23X, 74X, 75X, 83X) 1 = MPFS does not apply in a hospital outpatient setting. Only bill types 22X, 23X, 74X, 75X, 83X will be paid at the fee schedule. |
| CAT | DME Category code Valid Values: 1 ‑ Inexpensive or other routinely purchased DME 2 ‑ DME items requiring frequent maintenance and substantial servicing 3 ‑ Certain customized DME items 4 ‑ Prosthetic and orthotic devices 5 ‑ Capped rental DME items 6 ‑ Oxygen and oxygen equipment |
| PC TC | Professional Component/Technical Component (PC/TC) indicator - added to the Comprehensive Outpatient Rehabilitation Facility (CORF) extract of the Medicare Physician Fee Schedule Supplementary File. This is used to identify professional services eligible for the HPSA bonus payments. This field is only applicable when pricing CAH that have elected the optional method (Method 2) of payment (one-position alphanumeric field with four occurrences) |
| ANES BASE VAL | Anesthesia base unit value |
| TYP | MPFS Indicator ‑ Identifies whether the HCPCS originated from the MPFS database files and it paid off the fee rate (one-position alphabetic field with four occurrences) Valid Values: M ‑ Originated from MPFS database files Blank ‑ Did not originate from the MPFS database files |
| MSI | Multiple Service Indicator (one-position alphanumeric field) |
| ALLOWABLE REVENUE CODES | If the HCPCS code can only be billed with a specific revenue code(s), they will be displayed here. If this field is blank, then the HCPCS code that is being researched is allowable with any revenue code. |
| HCPC DESCRIPTION | Narrative description of the HCPCS code |
Prior effective/termination dates can be accessed by using the <F6/PF6> and <F5/PF5> keys.
To view rate information on the HCPC RATES INQUIRY screen, press the <F11/PF11> key:
| Field | Description |
|---|---|
| 60%RATE | Identifies the 60% Reimbursement Rate the system uses for calculating reimbursement for HCPCS/CPT codes. The system displays 60% of the total charge in a dollar figure (nine-position numeric field in 999999.999 format with four occurrences) |
| 62%/REDU | Identifies the 62% Lab Reimbursement Rate the system uses for calculating reimbursement for the lab HCPCS codes. The system displays 62% of the total charge in a dollar figure (10-position numeric field in 999999.999 format with four occurrences) |
| REHAB | Rate the system uses for calculating reimbursement for the HCPCS code when Rehabilitation Services are billed (nine-position numeric field in 999999.999 format with four occurrences) |
| PROF | Rate the system uses for calculating reimbursement for the HCPCS when Professional Services (revenue codes 96X, 97X or 98X) are billed by critical access providers that have selected provider reimbursement method I (nine-position numeric field in 999999.999 format with four occurrences) |
| NFACPE | PE RVU rate |
Revised 8/16/2023