Medicare Questions on Certification Exams

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There are a lot of different codes that we use in our coding of procedures that are based upon age. Something may not necessarily be age specific. There are a lot of different E/M codes that are age specific. Our preventative medicine, there is critical care codes that are specified by age. If they’re going to do age type of code, that’s where you’re going to see it like the critical care codes because it’s 48 months and younger. I’m trying to remember at the top of my head when I made this up. That’s where we’re going to see a lot of age codes.
When we’re dealing with the HCPCS itself, just remember that HCPCS originally started, they are for use with Medicare and Medicaid and some third party payers use those codes as well like you might see some of the S codes might be accepted by Blue Cross or some of the other plans. Typically, there is a specific section in HCPCS for medical assistance codes as well. A lot of these G codes will describe a more specific service. Level I is CPT; Level II is HCPCS. They’re all the same. They all are codings but Medicare specifically came out with this guide for codes that don’t easily assimilate to CPT.
Specifically on Medicare’s website, CMS.gov, they say because Medicare or other carriers have a variety of services that aren’t identified by CPT. They say there’s a lot of things out there that aren’t in CPT. They created Level II HCPCS codes for submitting claims for these items. If there is a Medicare question and they say a patient with Medicare came in, you might want to double check the codes that are being offered and if it is a better code description, it’s going to be a HCPCS code. It’s going to be a G code versus a CPT code.
These have a higher specificity. You think of CPT and they give you Fluzone and they give you 90653 and some of these other codes to say that we gave them a vaccination, but then we have the J codes. The J codes in HCPCS are very specific for the type of medication. You go by name for that type of medication. It is not just steroid. They’re giving you the name of the steroid that needs to be used. It’s very specific.
Those modifiers, all the HCPCS modifiers that we use, a whole lot of them, they’re used to specifically say the story to relay the exact information to the carrier about what’s going on. Typically a Medicare questions, you’re going to be drawn to the HCPCS guide because it’s made for Medicare and it is made to a higher level specificity than CPT codes.
I know it gets confusing. A lot of people go, “How am I supposed to know that?” It kind of comes with experience and if you take education or training, you’ll be thought that Medicare uses the HCPCS codes.