CPT / HCPCS and Local Coverage Determination


Once a CPT / HCPCS code was selected, Text2Codes will help you:

  • Pick the right ICD-10 Diagnosis code - supporting a specific CPT procedure in your region
  • Select the right CPT procedure code - supported by a specific diagnosis in your region
  • Avoid coding any ICD-10 Diagnosis or Procedure codes - expicitly not supporting a CPT procedure in your region
  • The CPT / HCPCS page displays top down: the code details, Medicare physician fees, Local coverage Determination (LCD) information specific to your location and all the relevant CPT code modifiers


    Medicare physician fees

    Click on the Show details button to review the details on Medicare physician fees - specific to your location

    Note: If the CPT code is Anesthesia related, better check the CPT Anesthesia fees calculator
    You can easily Modify your location / region settings
    Scrolling down, you'll see Indicators that may impact fees.

    These Indicators should not be confused with the CPT modifiers explained below


    Local Coverage Determination (LCD)

    On the page detailing a CPT / HCPCS code, below the physicians fees section, you can find information on your region specific LCD as determined by your Medicare carrier
    Click on the Show diagnosis and LCD button to review the LCD and the ICD-10 Diagnosis codes that may support a CPT code at your location

    LCD defines the ICD-10 diagnosis codes that support medical necessity for a CPT procedure in a specific region
    Basically, the diagnostic codes that your local Medicare carrier accepts as medical necessary to support a bill with a specific CPT procedure code
    The location for the LCD may be slightly different than the location considered for the physician fees above
    You can easily Modify your location / region settings
    Not all CPT procedure codes have LCD defining the ICD-10 Diagnosis codes supported in your area
    And there are situations where more than one LCD is covering a single CPT code in a specific region

    Sometimes, the LCD contains information on ICD-10 diagnostic codes explicitly not supporting a CPT code in your area

    The chances that a medical bill, with explicitly unaccepted ICD-10 diagnostic codes (LCD), will be paid fully and on time by your Medicare carrier are not very high

    Click on one of the LCD links, related to a CPT code and Text2Codes displays all the other CPT codes supported by the LCD, ICD-10 Diagnosis codes supported and those explicitly not supported, ICD-10 Procedure codes explicitly not supported (inpatients only), LCD Indication, CMS policy, additional information and your area Medicare contractors contact details (name, title, phone, email, web site of the MAC)


    Modifiers

    On the page detailing a CPT / HCPCS code, below the LCD section, you can find information on CPT, ASC and HCPCS level 2 modifiers
    Note: Anesthesia specific modifiers can be found on the CPT Anesthesia fees calculator page
    Hover over a modifier for more details


    Background

    From Wikipedia: The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
    CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim.
    ICD code sets also contain procedure codes but these are only used in the inpatient setting
    From CMS web site: The term ‘local coverage determination' means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).

    As a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000), all Local Medical Review Policies (LMRPs) were converted to LCDs.
    The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) of the Act. LMRPs may have also contained other information such as coding and payment guidelines. Coding and payment information that is not related to section 1862(a)(1)(A) is not contained in an LCD, Contractors communicate such information in related articles.

    For more information on LCD visit CMS web site
    A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code
    Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities

    Terms

    Assistant at Surgery
    Bilateral Surgery
    Calculation Flag
    Conversion Factor
    Co-Surgeons
    Endoscopic Base Code
    Facility NA Indicator
    Facility PE OPPS
    Facility PE RVU
    Facility Total RVU
    Formula Used
    Global Surgery Days
    Imaging Family Indicator
    Intra Op
    Modifier
    MP for OPPS
    Multiple Procedures
    MP RVU
    Non Facility NA Indicator
    Non Facility PE OPPS
    Non Facility PE RVU
    Non Facility Total RVU
    PC / TC Indicator
    Post Op
    Pre Op
    Status Code
    Supervision Diag. Procedure
    Team Surgery
    Work, PE, MP GPCI
    Work RVU


    For more information on CPT and RVU, visit CMS web site
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