HCPCS codes are maintained by the Centers for Medicare and Medicaid Services (CMS) and are revised by the federal agency every year. Though these changes are intended to streamline the reimbursement process and maximize hospitals’ incentive to provide care in the most efficient manner, they generally tend to add to the complication and create a degree of confusion among the healthcare providers. Let’s take a look at the complications that the latest HCPCS code modification has brought about-

One of the most prominent changes in this year’s revision is the roll out of four new HCPCS modifiers to define precise situations when it is appropriate to override a Correct Coding Initiative (CCI) edit. The move is intended to reduce inappropriate claim payments due to incorrect use of certain modifiers. However experts are not optimistic about the change. As per them, the roll out could potentially affect medical reimbursement. This is because they believe that rather than offering work relative value units (RVU) and adhering to the new and revised 2015 endoscopy codes, CMS generated new HCPCS G codes that map to the 2014 codes and preserve the values set in 2014, thus adding to confusion and diverse interpretation.

Experts feel that the most confusing aspect for physician coders in the current rule is the requirement for reporting new codes to Medicare. For instance if you have an endoscopy code that hasn’t changed from 2014 to 2015, nothing has changed and you’re going to report them like you always have. However if you have an endoscopy code that has been revised or deleted from 2014 to 2015, then you are going to have to report the new G codes to Medicare. If you fail to adhere by this new condition then your reimbursement is bound to suffer.

Thanks to the confusion, the medical fraternity is in a catch 22 situation and it is unclear whether or not private payers will accept the new G codes set forth by CMS. This has created a situation wherein each payer should be contacted prior to implementation to confirm that their system will accept the new G codes.

While a few healthcare players are plagued by the aforementioned confusion, others such as Advanced Medical Technology Association (AdvaMed) are worried about the deletion of a few codes and its adverse effect on the reimbursement of service providers. Their concern is prompted by the fact that CMS recently deleted several HCPCS codes for ventilators and replaced them with two new codes, which effectively means a 35 percent Medicare payment or reimbursement reduction.

The bottom line is reimbursement changes triggered by latest HCPCS code modification invite real costs to hospitals as it entails the need to retrain personnel to meet the new coding requirements, develop or purchase new MIS modules, implement new billing audit standards, and so on. And the reorientation doesn’t stop with billing and administrative staff. Clinical staffs have to be educated to become accustomed to CPT and HCPCS coding as these codes affect APC grouping, which in turn affects reimbursement.

The Way Out:

All the above mentioned tasks are pretty long and tedious. Going solo and managing it on your own can be quite a daunting task. Opting to outsource your billing service will save time, help you cope with HCPCS code changes and get faster reimbursements.


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