HCPCS — Healthcare Common Procedure Coding System
HCPCS (pronounced "hick-picks") is a coding system used primarily for Medicare and Medicaid billing. It codes services not covered by CPT — primarily supplies, equipment, drugs, and non-physician services.
HCPCS Structure
HCPCS has two levels:
Level I — CPT Codes
•5-digit numeric codes
•Maintained by AMA
•Used for physician services and procedures
•(Covered in CPT module)
Level II — HCPCS Codes
•Alphanumeric: one letter followed by 4 digits
•Maintained by CMS
•Used for: durable medical equipment, prosthetics, supplies, drugs, ambulance, non-physician services
•Updated quarterly (major updates January 1)
Format: [Letter][0000-9999]
A0000-A9999 Transportation services (Ambulance)
B0000-B9999 Enteral and parenteral therapy
C0000-C9999 Outpatient PPS (Hospital OPPS temporary)
D0000-D9999 Dental procedures (CDT codes)
E0000-E9999 Durable Medical Equipment (DME)
G0000-G9999 Procedures/Professional services (temporary)
H0000-H9999 Behavioral health services
J0000-J9999 Drugs administered other than oral method
K0000-K9999 Temporary DME codes
L0000-L9999 Orthotic and prosthetic procedures
M0000-M9999 Medical services
P0000-P9999 Pathology and laboratory
Q0000-Q9999 Temporary codes (miscellaneous)
R0000-R9999 Diagnostic radiology
S0000-S9999 Private payer temporary codes
T0000-T9999 State Medicaid agency codes
V0000-V9999 Vision/hearing services
Note: HCPCS Level II is updated quarterly by CMS (with major annual updates each January 1) — the codes, coverage rules, and NCD/LCD examples below are illustrative and long-standing but should be verified against a current CMS HCPCS release before use in real billing.
Key HCPCS Code Categories
E Codes — Durable Medical Equipment (DME)
DME must meet four criteria:
1.Durable (withstands repeated use)
2.Used for medical purpose
3.Not useful to person without illness/injury
4.Used in the home
Common E Codes:
E0100 Cane, includes canes of all materials
E0105 Cane, quad or tri (broad-based)
E0114 Crutches, underarm, pair
E0116 Crutch, underarm, each
E0130 Walker, rigid (pickup)
E0135 Walker, folding (pickup)
E0141 Walker, wheeled, without seat
E0143 Walker, folding wheeled
E0170 Commode chair
E0260 Hospital bed, semi-electric
E0601 CPAP device
E0627 Seat lift mechanism
E1150 Wheelchair, adult (standard)
E1161 Manual adult size wheelchair
E1390 Oxygen concentrator, single delivery port
J Codes — Injectable Drugs
J codes identify drugs administered by injection in physician offices and outpatient settings. Units represent specific quantities.
J0130 Abciximab, 10 mg
J0171 Adrenalin epinephrine, 0.1 mg
J0585 Botulinum toxin A per unit
J0702 Betamethasone acetate/sodium phosphate, 3 mg
J1020 Methylprednisolone acetate 20 mg
J1030 Methylprednisolone acetate 40 mg
J1040 Methylprednisolone acetate 80 mg
J1644 Heparin sodium, per 1000 units
J2001 Lidocaine HCl 10 mg
J2250 Midazolam HCl per 1 mg
J2405 Ondansetron HCl (Zofran) 1 mg
J2469 Palonosetron HCl 0.25 mg
J3030 Sumatriptan succinate 6 mg
J3301 Triamcinolone acetonide 10 mg
J3302 Triamcinolone acetonide 40 mg
J7030 Normal saline 500 mL
J9035 Bevacizumab (Avastin) 10 mg
G Codes — CMS Temporary Codes
Used for services that don't fit existing CPT codes, often Medicare preventive services.
G0008 Administration of influenza virus vaccine
G0009 Administration of pneumococcal vaccine
G0010 Administration of hepatitis B vaccine
G0101 Cervical or vaginal cancer screening (pelvic exam)
G0102 Prostate cancer screening, digital rectal exam
G0103 Prostate cancer screening, PSA test
G0121 Colorectal cancer screening, colonoscopy (not high risk)
G0202 Screening mammography
G0439 Annual wellness visit, subsequent
G0444 Annual depression screening
G0446 Annual face-to-face intensive behavioral therapy
MIPS Quality Reporting (G-codes):
G8420 Oncology measures
G9143 Patient on warfarin
A Codes — Transportation and Supplies
Ambulance:
A0425 Ground mileage, per statute mile
A0426 Ambulance service, ALS 1, emergency
A0427 Ambulance service, ALS 1, emergency (400 lb+)
A0428 Ambulance service, BLS, non-emergency
A0429 Ambulance service, BLS, emergency
A0430 Air ambulance, fixed wing
Supplies:
A4206 Syringe with needle, sterile (each)
A4207 Syringe with needle sterile, 2cc
A4245 Alcohol wipes, per box
A4253 Blood glucose test strips, per 50
A4259 Lancets, per box of 100
A6196 Alginate dressing, wound cover (per 6 sq in)
A6260 Wound cleanser, any type, any size
HCPCS Modifiers
HCPCS modifiers are two-digit alphanumeric codes appended to clarify services.
Anatomical modifiers:
-E1 Upper left, eyelid
-E2 Lower left, eyelid
-E3 Upper right, eyelid
-E4 Lower right, eyelid
-FA Left hand, thumb
-F1 Left hand, second digit
-F2 Left hand, third digit
-F3 Left hand, fourth digit
-F4 Left hand, fifth digit
-F5 to F9 Right hand digits
-TA Left foot, great toe
-T1 through T9 Other toe designations
-LC Left circumflex
-LD Left anterior descending
-RC Right coronary artery
DME modifiers:
-KX Requirements specified in LCD are met
-GZ Item expected to be denied as not reasonable/necessary
-GA Advance Beneficiary Notice (ABN) on file
-GY Item not covered by Medicare (statutory exclusion)
Symmetrical body parts:
-LT Left side
-RT Right side
-50 Bilateral procedure
Service level:
-UA Medicaid level of care 1
-UB Medicaid level of care 2
-TC Technical component
-26 Professional component
Coverage Determinations
National Coverage Determinations (NCDs):
- CMS sets national coverage policy
- Applies to all Medicare Administrative Contractors
- Example: NCD for CPAP (240.4) — must have sleep study
showing AHI ≥ 15, or AHI ≥ 5 with symptoms
Local Coverage Determinations (LCDs):
- MAC (Medicare Administrative Contractor) sets local policy
- Varies by geographic region
- Specifies ICD-10-CM codes that support medical necessity
- Example: LCD for glucose monitors requires diabetes diagnosis
Always verify:
1. Is it covered by Medicare?
2. Are there frequency limitations?
3. What ICD-10-CM codes support medical necessity?
4. Is prior authorization required?
Advance Beneficiary Notice (ABN)
ABN required when:
- Medicare may not cover the service
- Provider thinks it might be denied
ABN must include:
- Specific service expected to be denied
- Why Medicare may not pay
- Estimated cost
- Patient choice options
Patient options:
Option 1: Want item, bill Medicare, pay if denied
Option 2: Want item, don't bill Medicare, pay now
Option 3: Don't want item
Modifier codes for ABN:
-GA: ABN on file (mandatory claim submission)
-GX: ABN given voluntarily (optional services)
-GZ: Item likely non-covered, no ABN (provider absorbs cost)
-GY: Statutory exclusion (not covered by any Medicare benefit)
Interview Questions
What is the difference between CPT and HCPCS Level II?
CPT (Level I HCPCS) codes services and procedures performed by physicians — office visits, surgeries, diagnostic tests. These are 5-digit numeric codes maintained by the AMA and used universally. HCPCS Level II codes things CPT doesn't cover — durable medical equipment (walkers, wheelchairs, CPAP), injectable drugs by J-code, ambulance services, prosthetics and orthotics, and certain preventive services. Level II codes are alphanumeric, maintained by CMS, and primarily used for Medicare and Medicaid billing. Both may be used on the same claim.
When would you use HCPCS modifier -KX?
Modifier -KX is used for DME claims to indicate that the patient meets all the coverage criteria listed in the applicable Local Coverage Determination (LCD). For example, when billing for a power wheelchair, -KX indicates that documentation supports that the patient meets Medicare's functional and clinical criteria. Without -KX when required, the claim will be denied. -KX is essentially the provider's attestation that all LCD requirements are satisfied and documentation is in the medical record.
