SummaryCMS recently convened stakeholders for a public HCPCS meeting to discuss billing, coding, and reimbursement of non-drugs and non-biological products.
The Centers for Medicare & Medicaid Services (CMS) convenes biannual meetings with stakeholders to discuss potential updates to the Healthcare Common Procedure Coding System (HCPCS). This standardized coding system is divided into two subsets, HCPCS Level I and HCPCS Level II (see Table 1). HCPCS codes are used to identify specific items, services, and procedures on claims submitted to Medicare, Medicaid, and other health insurance programs in a consistent and orderly manner under the Health Insurance Portability and Accountability Act and implementing regulations.
|Code Set||Code Uses||Maintaining Body||Frequency of Updates|
|HCPCS Level I: Current Procedural Terminology (CPT), Fourth Edition||Procedures and services provided by physicians and other allied health professionals||American Medical Association||Yearly major updates with quarterly or Jan/July updates of certain code ranges|
|HCPCS Level II: National Healthcare Common Procedure Coding System||Drugs, supplies, equipment, non-physician services, and services not represented in CPT||CMS||Quarterly updates|
The biannual meetings are part of a larger CMS effort to improve the transparency of the coding system update process. The meetings serve as a platform for collaboration and consensus-building among experts in the field to ensure accurate and effective coding for healthcare services shaping the future of the HCPCS code set. Healthcare industry stakeholders (e.g., providers, payers, manufacturers, various professional organizations) and CMS officials discuss proposed code changes, additions, and deletions to the HCPCS Level II code set and review feedback from the healthcare community, consider emerging technologies and procedures, and evaluate the need for new codes or modifications to existing ones. The discussions also involve determining appropriate categorical payment for services and supplies covered by Medicare and Medicaid.
First 2023 HCPCS Meeting
CMS convened the first of two biannual meeting of 2023 in a virtual forum May 30–June 1 to focus on non-drug and non-biological coding updates. Items were placed on the public meeting agenda for new requests if the application for the item was complete and submitted through CMS’s HCPCS Level II application process in the current coding cycle or identified by CMS for public consideration. Avalere expects final decisions to be published in August 2023 for an effective date in September. Listed below are notable highlights from each of the three days of discussion.
Day 1 comprised two parts (part 1 and part 2). CMS considered a request related to an artificial intelligence-supported telemonitoring device, introducing questions on how new technologies may be distinguished from previous iterations of similar technology. This request also introduced questions on potential coverage under the durable medical equipment (DME) benefit.
- The product is being defined with a generic HCPCS Level II code that is not specific to the device. Rather, it is a supply code that includes a monitoring device/feature and its supplies.
- CMS indicated that a generic code could accurately describe the product and noted that the product does not fall under the DME benefit category since the device does not meet all DME requirements, including the requirement of the patient having to self-monitor/treat with use of device.
Day 2 saw a combined DME Benefit Determination request reviewed for the use of self-measured blood pressure (SMBP) devices. CMS clarified that most DME items are used in-home for therapeutic and self-management purposes, while SMBPs are generally not used by the patient to self-manage. CMS decided not to include SMBPs in the DME benefit category, although many commercial payers already view the products as DME and cover them as such.
After high-level overviews of several other products, CMS declined to change code descriptions and welcomed additional information surrounding the decisions.
Following public comment, CMS agreed on Day 3 to discontinue three S codes (HCPCS codes typically used by non-Medicare payers) concerning breast reconstruction (S2066, S2067, and S2068), effective December 31, 2024. Due to significant transition complexities that could affect access to care, CMS is accepting additional public input on whether the S codes should be retained or the end date should be extended.
CMS is also currently seeking comment on code descriptors for six newly established HCPCS Level II codes within the fourth quarter of 2022, effective April 1, 2023, and the established/revised 28 codes within the 1st quarter of 2023, effective July 1, 2023. The 505 (b)(2) pathway allows certain drug manufacturers to acquire Food and Drug Administration approval with another manufacturer’s product clinical data. The new codes CMS established will help reduce the use of not otherwise classified codes. Unexpectedly, there were no speakers on this topic.
CMS HCPCS biannual meetings are vital in maintaining an up-to-date and effective coding system that accurately represents the services and supplies provided in the healthcare industry. The collaborative nature of these meetings helps promote transparency, efficiency, and consistency in coding practices, ultimately benefiting healthcare providers, payers, and patients alike.
Avalere monitors CMS activity on HCPCS and other topics–work with us to anticipate and respond to public meetings, announcements, and other key actions. With expertise in coding, coverage, and reimbursement, we offer unparalleled support to navigate the complex landscape of the healthcare industry. To learn more, connect with us.
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