2013 Picks for HCPCS Level II

Effective Jan. 1, 2013, there are 150 changes, plus lots of quality performance measurement G code updates.

By G.J. Verhovshek, MA, CPC
Since April 1, 2012, the HCPCS Level II code set has undergone approximately 150 individual changes, not counting those G codes used for reporting to the Physician Quality Reporting System (PQRS) or Medicare demonstration projects (more on those below).

New Modifiers

Among the changes are seven new modifiers for Medicare reporting, which must be appended to HCPCS Level II codes G8978-G9176 (new for 2013) to describe a functional limitation (e.g., G8981-G8983 Changing and maintaining body position functional limitation …). The modifiers describe the extent of the functional limitation.
CH     0 percent impaired, limited or restricted
CI       At least 1 percent but less than 20 percent impaired, limited or restricted
CJ      At least 20 percent but less than 40 percent impaired, limited or restricted
CK     At least 40 percent but less than 60 percent impaired, limited or restricted
CL      At least 60 percent but less than 80 percent impaired, limited or restricted
CM     At least 80 percent but less than 100 percent impaired, limited or restricted
CN     100 percent impaired, limited or restricted
The G codes with modifiers must be reported at regular intervals for Medicare patients who receive outpatient therapy services, including:

  • At the outset of therapy episode
  • On or before every 10 treatment days throughout the course of therapy
  • At the time of discharge from therapy
  • At the time the beneficiary’s condition, changes significant enough to clinically warrant a re-evaluation such that a HCPCS/CPT® code for a re-evaluation or a repeat evaluation is billed

Also new are two modifiers that may be used to “break” National Correct Coding Initiative (NCCI) edits, when appropriate. Modifiers LM Left main coronary artery and RI Ramus intermedius coronary artery alert the payer that two procedures occurred at separate sites and may be reimbursed separately, similar to modifiers LT Left side and RT Right side.
Modifiers V8 and V9, previously used with dialysis revenue code lines for all end stage renal disease (ESRD) claims and all ESRD hemodialysis claims, were deactivated April 1, 2012.

New Supply Codes

As always, there has been plenty of action when it comes to drug supply codes as temporary codes transition to permanent status and new drugs are added. See Table 1 for details.
And as shown in Table 2, there has been a lot of movement in codes used to describe skin substitutes.

Matching HCPCS and CPT® Changes

The Centers for Medicare & Medicaid Services (CMS) designated several new HCPCS Level II codes to take the place of CPT® codes for Medicare reporting.
For example, since 2003, CMS has assigned coronary stent placement procedures to separate ambulatory payment classifications based on the use of nondrug-eluting or drug-eluting stents. To enact this policy, CMS created G0290 and G0291, which corresponded to CPT® codes 92980 and 92981. For 2013, CPT® deleted 92980 and 92981, replacing them with new, more granular codes describing coronary therapeutic services and procedures.
To maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, CMS designated new HCPCS Level II C codes to parallel the new CPT® codes:


C9600 = 92920

C9601 = 92921

C9602 = 92924

C9603 = 92925

C9604 = 92937

C9605 = 92938

C9606 = 92941

C9607 = 92943

C9608 = 92944

Consult Table 3 on the next page for a list of other new HCPCS Level II codes, some of which were created to take the place of CPT® codes for Medicare reporting.
Another interesting code is Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose, which is newly established to report Tc-99m from non-highly enriched uranium (HEU) sources. TC-99m is the most widely used radioisotope for diagnosing diseased organs. For 2013, CMS will make an additional payment of $10 to cover the marginal costs associated with non-HEU Tc-99m production.
In some cases, newly-created CPT® codes have taken the place of now-deleted HCPCS Level II codes. For example, Category III CPT® code 0308T Insertion of ocular telescope prosthesis including removal of crystalline lens replaced C9732 for ocular telescope prosthesis with removal of crystalline lens, while many pathology procedures in the range S3711-S3860 have been deleted and replaced with new CPT® codes describing molecular pathology and multianalyte assays with algorithmic analysis (e.g., 81200-81408, 81500-81512, 81599, and 86152-86153).
Finally, V5267 has been revised to specify Hearing aid or assistive listening device/supplies/accessories, not otherwise specified, and 10 new codes have been added to describe personal FM/DM auditory devices, which are used with hearing aids to improve the signal-to-noise ratio, allowing the listener to hear better in the presence of background noise.
Table 1

New Code Old Code Drug Trade Name
A9586   Florbetapir f18 AMYVID™
C9290   Bupivacaine liposome Exparel™
C9292   Pertuzumab Perjeta™
C9293   Glucarpidase Voraxaze®
C9294   Taliglucerase alfa Eleyso™
C9295   Carfilzomib  
C9296   Ziv-aflibercept Zaltrap®
J0178 C9291 Aflibercept EYLEA®
J0485 C9286 Belatacept Nulojix®
J0716 C9288 Centruroides (scorpion) immune F(AB)2 Anascorp®
J0890 Q2047 Peginesatide  
J1051 Medroxyprogesterone acetate  
J1741 C9279 Ibuprofen Caldolor™
J1744   Icatibant IRAZYR®
J2212   Methylnaltrexone Relistor®
J1680 Human fibrinogen
Q2046   Aflibercept  
J7315   Mitomycin, ophthalmic Mitosol™
J7527   Everolimus Zortress®
J9001 Doxorubicin
J9019 C9289 Asparaginase (erwinze) Erwinaze™
J9020 J9020 Asparaginase, not
otherwise specified
J9042 C9287 Brentuximab vedotin Adcetris™
Q2034   Influenza virus
vaccine, split virus
Q2049   Doxorubicin hydrochloride, liposomal Imported
S1090*   Mometasone furoate sinus implant Propel™

*Medicare does not accept S codes.
Table 2

New Code Old Code Product
Q4119   MatriStem PSMX, RS, and PSM
Q4126   Memoderm, dermaspan, tranzgraft, or integuply
Q4128   Flex HD, Allopatch HD, or Matrix HD
Q4131 C9366 Epifix
Q4132 C9368 Grafix®CORE
Q4133 C9369 Grafix®PRIME
Q4134   hMatrix
Q4135   Mediskin
Q4136   Ez-Derm

Table 3

HCPCS CPT® Service
C9733 N/A SPY® and other non-ophthalmic fluorescent vascular angiography
G0452 N/A Molecular pathology procedure; physician interpretation and report
G0453 95941 Continuous intraoperative neurophysiology monitoring outside the operating room
G0454 N/A Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant, or clinical nurse specialist
G0455 44705 Preparation with instillation of fecal microbiota by any method
S0596* N/A Phakic intraocular lens for correction of refractive error
S0353* N/A Treatment planning and care coordination management for cancer, initial
S0354* N/A Treatment planning and care coordination management for cancer, established patient with a change of regimen
* Medicare does not accept S codes


Physician Quality Reporting and Medicare Demonstration Projects

G codes in the range G8000–G8999 are designated PQRS codes. Since April 1, 2012 there have been 114 code additions, 48 code deletions, and 122 code revisions to the G codes used to report quality performance measurements.
Eligible professionals (EPs) who successfully report on quality measures in the PQRS are eligible for a 0.5 percent Medicare payment incentive for years 2012-2014. In 2015, EPs and groups that do not report quality data successfully will face a 1.5 percent payment reduction in Medicare payments, and a 2 percent reduction for 2016. For additional information about PQRS, visit the CMS website.
G codes in the range G9000–G9999 are applied for Medicare Demonstration Project reporting. Since April 1, 2012, there have been 21 new codes and two code deletions in this section. For more information on Medicare Demonstration Projects, visit the CMS website.

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G.J. Verhovshek, MA, CPC, is managing editor at AAPC.


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