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Dressings used on day of service are included within the APC (Ambulatory Payment Classification) payment.
Dressings used at home between visits may be supplied by a DME and billed separately to Medicare Part B if coverage criteria are met
- Medical necessity requirements for coverage;
- Patient diagnosis that supports the medical necessity for the dressing, technology, or service;
- Codes verified by the Centers for Medicare & Medicaid Services (CMS), Pricing, Data Analysis Contractor (PDAC), the American Medical Association (AMA) or other appropriate source;
- Fee schedule, assigned payment amount, or procedure for determining the amount reimbursed.
Healthcare Common Procedure Coding System
HCPCS is divided into two principal subsystems, referred to as Level I and Level II
- Level I is comprised of the CPT-4, a numeric coding system maintained by the AMA to identify medical services and procedures furnished by physicians and other health care professionals.
- Level II HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes. It is maintained and distributed by CMS, in conjunction with private payer organizations.
Level 1 HCPCS
Level I HCPCS contains the AMA Physicians’ Current Procedural Terminology (CPT-4). Each code is 5 numeric digits with a descriptive term. These codes are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals
example of a Level I HCPCS code applicable to wound care:
97597Removal of devitalized tissue from wound(s); selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters
Level II HCPCS is a standardized coding system used to identify products, supplies, and services
Also included in Level II HCPCS are Outpatient Prospective Payment System (OPPS) status indicators which identify how individual codes are paid or not paid under the Medicare outpatient prospective payment system.
Outpatient Prospective payment system OPPS
This section may include device categories, new technology procedures and drugs, biologicals, and radiopharmaceuticals that do not have other HCPCS codes assigned. Some of these items and services are eligible for transitional pass-through payments for OPPS hospitals, have separate APC payments, or are items that are packaged
A set of temporary codes are also included in the Level II HCPCS. These may be changed, added, or deleted on a quarterly basis. Once established, temporary codes are usually implemented within 90 days.
There are temporary “G” codes for procedures/professional services that would otherwise be coded in CPT but for which there are no CPT codes. There are temporary “K” codes established for use by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs). These are developed when the current existing permanent national codes for supplies and certain product categories do not include the codes needed to implement a DME MAC medical review policy under Medicare Part B.
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