HCPCS Level II
HCPCS Level II is used to report many healthcare products, supplies and services not represented by CPT. Depending on the service and payer, this can include items such as durable medical equipment, certain drugs, supplies and ambulance services.
What a modifier does
A modifier is appended to a procedure or service code to communicate additional information about the circumstances of the service. A modifier does not replace documentation and should only be used when its requirements are met.
Modifier concepts billers commonly encounter
Distinct circumstances
Some modifiers communicate that a service should be considered separately under defined rules.
Professional / technical components
Certain services can involve separate professional interpretation and technical components.
Laterality
Some claim workflows use modifiers to communicate right or left side when appropriate.
Service circumstances
Modifiers can communicate special circumstances such as repeat, staged or other defined situations.
Common billing problems
- A payer edit expects a modifier but none is present.
- A modifier is used but documentation does not support its meaning.
- Professional and technical components are billed incorrectly.
- HCPCS units do not match the documented quantity or payer unit definition.
- The wrong payer-specific billing rule is applied.
Quick knowledge check
What type of items may be reported with HCPCS Level II?
Many supplies, products and services not represented by CPT, including selected DME and drugs.
What is the purpose of a modifier?
To communicate additional information about the circumstances of a procedure or service.
Should a modifier be added only to make an edit disappear?
No. It must be supported by documentation and applicable rules.
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