HCPCS Code Modifiers

Your Online Resource for HCPCS Code Information

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Code Modifiers in HCPCS System

In some instances, insurers instruct suppliers that a HCPCS code must be accompanied by code modifier to provide additional information regarding the service or item identified by the HCPCS code.

Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service. For example, a UE modifier is used when the item identified by a HCPCS code is "used equipment," a NU modifier is used for "new equipment." The level II HCPCS modifiers are either alpha-numeric or two letters.

Requesting a Modification to the HCPCS Level II Codes

Any supplier or manufacturer can submit a request for coding modification to the HCPCS Level II national codes. A requestor should also submit any additional descriptive material, including the manufacturer's product literature and information, that it thinks would be helpful in furthering our understanding of the medical features of the item for which a coding modification is being recommended. The HCPCS coding review process is an ongoing continuous process. The review cycle runs from April 2nd through the following April 1st.

Requests may be submitted at any time throughout the year. Requests that are received and complete by April 1st of the current year will be considered for inclusion in the next annual update (January 1st of the following year). Requests received on or after April 2nd, and requests received earlier that require additional evaluation, will be included in a later HCPCS update.

There are three types of coding modifications to the HCPCS that can be requested:

  1. That a code be added
  2. When there is not a distinct code that describes a product, a code may be requested (1) if the FDA allows the product to be marketed in the United States, (2) the product has been on the market for at least 6 months, and (3) the product represents 3 percent or more of the outpatient use for that type of product in the national market.

    If a request for a new code is approved, the addition of a new HCPCS codes does not mean that the item is necessarily covered by Medicare. Whether an item identified by a new code is covered is determined by the Medicare law, regulations, and medical review policies and not by the assignment of a code.

  3. That the language used to describe an existing code be changed
  4. When there is an existing code, a recommendation to modify the code can be made when an interested party believes that the descriptor for the code needs to be modified to provide a better description of the category of products represented by the code.

  5. That an existing code be deleted

When an existing code becomes obsolete or is duplicative of another code, a request can be made to delete the code.

During any time in which there is no currently existing code to describe a product, a miscellaneous code/not otherwise classified code can be used. The use of a miscellaneous code permits a claims history to be established for an item that can be used to support the need for a national permanent code.

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