The HIPAA or Health Insurance Portability and Accountability Act of 1996, instructs medical healthcare plans to use the standard electronic transactions adopted under this agency by using the following valid standard codes. Medicare policy requires that CARCs should provide a supplemental explanation why a claim or service line was paid differently than it was billed.
The Centers for Medicare & Medicaid Services (CMS) staff usually requests changes in the code when it directly affects the Medicare policy. Shared System Maintainers (SSMs) and Medicare contractors are notified about all the necessary changes. If a modification has been implemented by an entity outside CMS for a code currently used by Medicare, Medicare Administrative Contractors (MACs) must either use the existing modified code or another code. If any new or modified code has an effective date past the implementation date specified in CR9004, MACs will implement on the date specified on the WPC website.
The Centers for Medicare & Medicaid Services (CMS) maintain and annually update a List of Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) Codes (Code List), which identifies all the items and services included within certain DHS categories. CMS updates the Code List to conform the list to the most recent publications of CPT and HCPCS and to account for changes in Medicare coverage and payment policies. The updated Code List is published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. That rule is usually published in November and generally becomes effective January 1 of the following year. In addition, we may publish other rules or correction notices that may change the Code List. CMS posts any changes to the Code List on its webpage as soon as possible after publication in the Federal Register.
The DHS categories defined by the Code List are:
– Clinical laboratory services;
– Physical therapy services, occupational therapy services, outpatient speech-language pathology services;
– Radiology and certain other imaging services; and
– Radiation therapy services and supplies.
**NOTE**: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:
– Durable medical equipment and supplies;
– Parenteral and enteral nutrients, equipment and supplies;
– Prosthetics, orthotics, and prosthetic devices and supplies;
– Home health services;
– Outpatient prescription drugs; and
– Inpatient and outpatient hospital services.