A federal program that requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations and covered entities at significantly reduced prices, with specific billing and coding requirements.
Version 5010 is an electronic data interchange (EDI) standard used for transmitting healthcare claims, including HCPCS and other coding data, which replaced the previous version 4010 to improve efficiency and support the adoption of ICD-10 codes.
Ambulatory Surgical Center is a healthcare facility that specializes in providing outpatient surgical services, which are billed using HCPCS codes.
A subset of HCPCS Level II codes used to report services and supplies related to ambulatory care and outpatient services, such as dressing materials and some medications.
Ambulatory Payment Classification is a system used by CMS to group outpatient services with similar resource utilization and clinical characteristics, using HCPCS codes to determine payment rates under the OPPS.
Advance Beneficiary Notice is a form used by healthcare providers to inform Medicare beneficiaries of their financial responsibility for services or items that are not covered by Medicare, which may involve HCPCS codes and billing information.
Accountable Care Organization is a group of healthcare providers and facilities that voluntarily collaborate to provide coordinated, high-quality care to Medicare beneficiaries, with shared financial incentives based on performance measures, which may include HCPCS codes and other coding data.
Additional Documentation Request is a request from a payer, such as Medicare or a commercial insurance company, for further documentation or information to support a submitted claim, which may include details related to HCPCS codes, CPT codes, or ICD-10 codes.
A subset of HCPCS Level II codes used to report enteral and parenteral nutrition services and supplies, such as feeding tubes and intravenous nutrients.
Current Procedural Terminology codes are a subset of HCPCS Level I codes, developed by the American Medical Association, used to report medical procedures and services performed by healthcare providers.
Centers for Medicare & Medicaid Services is the federal agency responsible for administering Medicare, Medicaid, and other health programs, including oversight of the HCPCS coding system.
Conditionally Required is a coding modifier used in claims submission to indicate that a specific HCPCS or CPT code is required under certain conditions, as determined by CMS or other regulatory bodies.
Critical Access Hospital is a rural healthcare facility designated by CMS to provide essential healthcare services to rural communities, with specific HCPCS and billing requirements to ensure adequate reimbursement.
Clinical Laboratory Improvement Amendments are federal regulations that establish quality standards for laboratory testing, with specific coding and billing requirements for laboratory services under the HCPCS system.
Correct Coding Initiative is a CMS program that develops and maintains NCCI edits to ensure correct coding and billing practices, prevent improper payments, and promote efficient use of healthcare resources.
Claim Adjustment Reason Code is a code used by insurance companies to communicate the reason for payment adjustments or denials in a standardized format, often based on HCPCS or CPT codes.
Consolidated Renal Operations in a Web-Enabled Network is an online data collection system used by CMS to collect clinical and administrative data on end-stage renal disease (ESRD) patients, including information related to HCPCS codes.
Coordination of Benefits is a process used by insurance companies to determine the primary and secondary payers when a patient has more than one healthcare plan, which can impact the processing and payment of claims involving HCPCS codes.
Comprehensive Error Rate Testing is a program administered by CMS to measure the accuracy of Medicare claims payment processes, including the correct use of HCPCS codes, and identify areas for improvement in payment accuracy.
Community Health Center is a nonprofit healthcare organization that provides comprehensive primary care services, including medical, dental, and behavioral health services, to underserved populations, with specific HCPCS and billing requirements to ensure adequate reimbursement.
Durable Medical Equipment refers to reusable medical equipment, such as wheelchairs and oxygen concentrators, which are coded using HCPCS Level II codes.
Diagnosis-Related Group is a system used to classify hospital cases and determine payment rates for inpatient services, based on diagnoses and procedures.
Explanation of Benefits is a document provided by insurance companies that outlines the services, HCPCS codes, and payment amounts associated with a healthcare claim.
A subset of HCPCS Level II codes used to report durable medical equipment (DME) and related supplies, including items like hospital beds, wheelchairs, and blood glucose monitors.
Employee Retirement Income Security Act is a federal law that sets minimum standards for employer-sponsored health plans, with implications for healthcare billing and coding, including the use of HCPCS codes and related reimbursement policies.
Electronic Health Record is a digital version of a patient’s medical history, which can include information related to HCPCS codes, CPT codes, and ICD-10 codes, and is designed to improve the efficiency and quality of healthcare by facilitating data sharing among providers.
A comprehensive list of payment rates for specific medical services, procedures, and supplies, based on HCPCS codes.
A subset of HCPCS Level II codes used to report services and procedures related to rehabilitative and psychiatric care, such as mental health counseling and substance abuse treatment.
A subset of HCPCS Level II codes used to report services and procedures not covered by CPT codes, often used for Medicare-specific services.
Healthcare Common Procedure Coding System codes are a set of alphanumeric codes used to identify medical services, procedures, and supplies for billing and reporting purposes.
Health Insurance Portability and Accountability Act is a federal law that protects patients’ medical records and personal health information.
Home Health Resource Group is a system used to classify home health services and determine payment rates based on patient characteristics, clinical severity, and therapy needs, using HCPCS codes.
Hospital-Acquired Condition is a medical condition or complication that a patient acquires during a hospital stay, which may impact payment rates under the Inpatient Prospective Payment System (IPPS) or other payment systems, based on the coding of the condition in the claim.
Hierarchical Condition Category is a risk adjustment model used by CMS to predict healthcare costs based on patient demographics, health conditions, and other factors, using ICD-10 codes to identify and classify conditions.
Healthcare Effectiveness Data and Information Set is a widely used set of performance measures developed by the National Committee for Quality Assurance (NCQA) to evaluate the quality of healthcare plans and providers, often incorporating HCPCS codes and other coding data.
An annual update to the HCPCS Level II codes, including additions, deletions, and revisions, released by CMS to reflect changes in medical technology, services, and reimbursement policies.
International Classification of Diseases, 10th Revision, is a standardized system for classifying diseases, injuries, and causes of death, used for diagnostic coding.
A subset of HCPCS Level II codes used to report services and procedures related to dental care, including dental examinations, treatments, and oral surgery.
A subset of HCPCS Level II codes used to report injectable drugs and biologicals.
A subset of HCPCS Level II codes used to report temporary codes for items and services related to DME, prosthetics, orthotics, and supplies (DMEPOS) that are not classified under other HCPCS code categories.
The first level of HCPCS codes, primarily comprised of CPT codes, used for reporting medical procedures and services.
The second level of HCPCS codes, alphanumeric codes used for reporting non-physician services, supplies, and equipment.
A subset of HCPCS Level II codes used to report orthotic and prosthetic services, such as braces, splints, and artificial limbs.
Local Coverage Determination is a policy issued by a Medicare Administrative Contractor (MAC) that provides coverage information for specific services, procedures, or items within a particular region, based on HCPCS codes.
Two-digit codes appended to HCPCS or CPT codes to provide additional information or clarification about a procedure or service.
A subset of HCPCS Level II codes used to report miscellaneous services, such as case management, care plan oversight, and other services not classified under other HCPCS code categories.
Medicare Administrative Contractor is a private company contracted by CMS to process Medicare claims, issue coverage determinations, and enforce billing rules, including those related to HCPCS codes.
MUEs are edits used by CMS to limit the number of units of service for a single HCPCS or CPT code that a provider can bill for a single patient on a single day, based on medical necessity and utilization guidelines.
Medicare Physician Fee Schedule is a comprehensive list of payment rates for physician services, based on HCPCS codes, which is used to determine reimbursement rates for Medicare Part B services provided by physicians and other healthcare professionals.
Merit-Based Incentive Payment System Alternative Payment Model is a type of value-based payment model under the Quality Payment Program (QPP), designed to reward eligible clinicians for providing high-quality, cost-effective care while participating in innovative payment arrangements with CMS.
Medicare Learning Network is an educational resource provided by CMS that offers healthcare providers, suppliers, and other stakeholders access to educational materials, web-based training courses, and other resources related to Medicare billing, coding, and reimbursement, including information on HCPCS codes and their proper use.
National Correct Coding Initiative edits are pairs of HCPCS or CPT codes that should not be billed together to prevent improper payments and promote correct coding practices.
National Drug Code is a unique, 10-digit code used to identify prescription drugs and certain over-the-counter products.
National Coverage Determination is a policy issued by CMS that determines whether a particular medical service, procedure, or item is covered under Medicare, often based on HCPCS codes.
National Provider Identifier is a unique, 10-digit identification number assigned to healthcare providers in the United States, used for billing and administrative purposes, including submitting claims with HCPCS codes.
National Uniform Billing Committee is an organization that develops and maintains the UB-04 form, a standardized billing form used by hospitals, skilled nursing facilities, and other institutional providers to submit claims with HCPCS codes.
National Plan and Provider Enumeration System is an online system used by healthcare providers to apply for a National Provider Identifier (NPI) and maintain their NPI record, which is essential for billing and administrative purposes, including submitting claims with HCPCS codes.
National Council for Prescription Drug Programs is a nonprofit organization that develops and maintains standards for electronic data exchange related to pharmacy services, including the use of National Drug Codes (NDCs) and other coding systems.
Outpatient Prospective Payment System is a CMS system that reimburses hospitals for outpatient services based on HCPCS codes, with payment rates determined by the Ambulatory Payment Classification (APC) system.
A subset of HCPCS Level II codes used to report services and procedures related to obstetrics and gynecology, including prenatal care, childbirth, and reproductive health services.
Office of Inspector General is a federal agency responsible for protecting the integrity of healthcare programs, such as Medicare and Medicaid, by detecting and preventing fraud, waste, and abuse, including issues related to HCPCS coding and billing.
Physician Quality Reporting System was a CMS program that encouraged healthcare professionals to report quality data using specific HCPCS codes. It was replaced by the Merit-Based Incentive Payment System (MIPS) under the Quality Payment Program (QPP) in 2017. MIPS consolidates and streamlines various quality reporting programs, including PQRS, into a single performance measurement system for eligible clinicians, with the goal of improving patient care and reducing administrative burdens.
A subset of HCPCS Level II codes used to report pathology and laboratory services, including diagnostic tests, screenings, and specimen collection.
Place of Service is a two-digit code used on healthcare claims to indicate the location where a service was provided, such as a physician’s office, hospital, or outpatient facility, which can impact reimbursement rates based on HCPCS codes.
Program for Evaluating Payment Patterns Electronic Report is a data analysis tool provided by CMS that helps healthcare providers identify areas of potential improper payments, including those related to HCPCS coding and billing practices, by comparing their claims data to national and regional benchmarks.
A subset of HCPCS Level II codes used to report temporary codes for outpatient hospital services, drugs, biologicals, and other medical services not classified under other HCPCS code categories.
Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Resource-Based Relative Value Scale is a system used by CMS to determine reimbursement rates for services based on the relative resources required to perform them.
Relative Value Units are numeric values assigned to HCPCS codes that reflect the resources required for a given service, used to calculate payment rates.
A subset of HCPCS Level II codes used to report services and procedures related to diagnostic and interventional radiology, including ultrasounds, nuclear medicine, and angiography.
Remittance Advice Remark Code is a code used in conjunction with a CARC to provide additional information or clarification about payment adjustments or denials, helping providers understand the specifics of claim processing.
Relative Value Update is an annual adjustment to the Relative Value Units (RVUs) used in the Medicare Physician Fee Schedule, which takes into account changes in medical practice, technology, and resource costs, and may impact reimbursement rates for services based on HCPCS codes.
Risk Adjustment Factor is a value used in risk adjustment models, such as the Hierarchical Condition Category (HCC) model, to predict healthcare costs and allocate resources based on patient demographics, health conditions, and other factors, using ICD-10 codes and other coding data.
A subset of HCPCS Level II codes used to report private payer codes for services and procedures not covered by Medicare, including some services provided in a dental office, physical therapy, and other non-covered services.
Skilled Nursing Facility is a healthcare facility that provides short-term skilled nursing care, rehabilitation services, and other healthcare services to patients who require a level of care not available in an outpatient setting, with specific HCPCS and billing requirements.
A subset of HCPCS Level II codes used to report state Medicaid agency codes for services not included in other HCPCS code categories.
TRICARE is a healthcare program for active-duty and retired military personnel, their families, and survivors, which utilizes HCPCS codes for billing and reimbursement purposes, similarly to Medicare and Medicaid.
A subset of HCPCS Level II codes used to report temporary codes for unique products or services that do not fit into existing code categories, typically assigned by CMS on a case-by-case basis.
A subset of HCPCS Level II codes used to report vision and hearing services, such as eyeglasses, contact lenses, and hearing aids.
