Procedure/HCPCS Codes Overview

The codes used for submitting claims for services provided to Colorado Medical Assistance Program members represent services that are approved by the Centers for Medicare and Medicaid Services (CMS) and services that may be provided by an enrolled Colorado Medical Assistance Program provider.

The Healthcare Common Procedural Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). 

The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. 

Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. 

Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.

HIPAA requires providers to comply with the coding guidelines of the AMA CPT Procedure Codes and the International Classification of Disease, Clinical Modification Diagnosis Codes. 

If there is no time designated in the official descriptor, the code represents one unit or session. Providers should regularly consult monthly bulletins in the Provider Services  Bulletins section. 

To receive electronic provider bulletin notifications, an email address can be entered into the Web Portal in the (MMIS) Provider Data Maintenance area or by filling out a publication preference form. Bulletins include updates on approved procedure codes as well as the maximum allowable units billed per procedure.

Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field #	Field Label	Field is?	Instructions
1	Insurance Type	Required	Place an “X” in the box marked as Medicaid.
1a	Insured’s ID Number	Required	Enter the client’s Colorado Medical Assistance Program seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2	Patient’s Name	Required	Enter the client’s last name, first name, and middle initial.

CMS Field #	Field Label	Field is?	Instructions
3	Patient’s Date of Birth / Sex	Required	Enter the patient’s birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014. Place an “X” in the appropriate box to indicate the sex of the client.
4	Insured’s Name	Conditional	Complete if the client is covered by a Medicare health insurance policy. Enter the insured’s full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5	Patient’s Address	Not Required
6	Patient’s Relationship to Insured	Conditional	Complete if the client is covered by a commercial health insurance policy. Place an “X” in the box that identifies the client’s relationship to the policyholder.
7	Insured’s Address	Not Required
8	Reserved for NUCC Use
9	Other Insured’s Name	Conditional	If field 11d is marked “YES”, enter the insured’s last name, first name and middle initial.
9a	Other Insured’s Policy or Group Number	Conditional	IF field 11d is marked “YES”’ enter the policy or group number.
9b	Reserved for NUCC Use
9c	Reserved for NUCC Use

CMS Field #	Field Label	Field is?	Instructions
9d	Insurance Plan or Program Name	Conditional	If field 11d is marked “YES”, enter the insurance plan or program name.
10a-c	Is Patient’s Condition Related to?	Conditional	When appropriate, place an “X” in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d	Reserved for Local Use
11	Insured’s Policy, Group or FECA Number	Conditional	Complete if the client is covered by a Medicare health insurance policy. Enter the insured’s policy number as it appears on the ID card. Only complete if field 4 is completed.
11a	Insured’s Date of Birth, Sex	Conditional	Complete if the client is covered by a Medicare health insurance policy. Enter the insured’s birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. Place an “X” in the appropriate box to indicate the sex of the insured.
11b	Other Claim ID	Not Required
11c	Insurance Plan Name or Program Name	Not Required
11d	Is there another Health Benefit Plan?	Conditional	When appropriate, place an “X” in the correct box. If marked “YES”, complete 9, 9a and 9d.
12	Patient’s or Authorized Person’s signature	Required	Enter “Signature on File”, “SOF”, or legal signature. If there is no signature on file, leave blank or enter “No Signature on File”.

CMS Field #	Field Label	Field is?	Instructions
			Enter the date the claim form was signed.
13	Insured’s or Authorized Person’s Signature	Not Required
14	Date of Current Illness Injury or Pregnancy	Conditional	Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. Enter the applicable qualifier to identify which date is being reported. 431       Onset of Current Symptoms or Illness 484       Last Menstrual Period
15	Other Date	Not Required
16	Date Patient Unable to Work in Current Occupation	Not Required
17	Name of Referring Physician	Not Required
18	Hospitalizatio n Dates Related to Current Service	Conditional	Complete for services provided in inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. If the client is still hospitalized, the discharge date may be omitted. This information is not edited.

CMS Field #	Field Label	Field is?	Instructions
19	Additional Claim Information	Conditional	LBOD Use to document the Late Bill Override Date for timely filing.
20	Outside Lab? $ Charges	Conditional	Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office. Practitioners may not request payment for services performed by an independent or hospital laboratory.
21	Diagnosis or Nature of Illness or Injury	Required	Enter at least one but no more than twelve diagnosis codes based on the client’s diagnosis/condition. Enter applicable ICD indicator to identify which version of ICD codes is being reported. 0         ICD-10-CM (DOS 10/1/15 and after) 9         ICD-9-CM (DOS 9/30/15 and before)
2	Medicaid Resubmission Code	Conditional	List the original reference number for adjusted claims. When resubmitting a claim as a replacement or a void, enter the appropriate bill frequency code in the left- hand side of the field. 7         Replacement of prior claim 8         Void/Cancel of prior claim This field is not intended for use for original claim submissions.
23	Prior Authorization	Not Required

CMS Field #	Field Label	Field is?	Instructions
4	Claim Line Detail	Information	The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line. Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing. Each claim form must be fully completed (totaled). Do not file continuation claims (e.g., Page 1 of 2).
4A	Dates of Service	Required	The field accommodates the entry of two dates: a “From” date of services and a “To” date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016 From            To 01  01  16 Or From            To 01  01  16  01  01  16 Span dates of service From            To 01  01  16  01  31  16 Single Date of Service: Enter the six digit date of service in the “From” field. Completion of the “To field is not required. Do not spread the date entry across the two fields. Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
24B	Place of Service	Required	Enter the Place of Service (POS) code that describes the location where services were rendered. The Colorado Medical Assistance Program accepts the CMS place of service codes.

CMS Field #	Field Label	Field is?	Instructions
			11            Office
24C	EMG	Conditional	Enter a “Y” for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention. If a “Y” for YES is entered, the service on this detail line is exempt from co- payment requirements.
24D	Procedures, Services, or Supplies	Required	Enter the SCI procedure code that specifically describes the service for which payment is requested.
24D	Modifier	Not Required
24E	Diagnosis Pointer	Required	Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis. At least one diagnosis code reference letter must be entered. When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow. This field allows for the entry of 4 characters in the unshaded area.
24F	$ Charges	Required	Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number. Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

CMS Field #	Field Label	Field is?	Instructions
			The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed. Submitted charges cannot be more than charges made to non-Colorado Medical Assistance Program covered individuals for the same service. Do not deduct Colorado Medical Assistance Program co-payment or commercial insurance payments from the usual and customary charges.
24G	Days or Units	Required	Enter the number of services provided for each procedure code. Enter whole numbers only- do not enter fractions or decimals.
24H	EPSDT/Family Plan	Conditional	EPSDT (shaded area) For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows: AV           Available- Not Used S2            Under Treatment ST           New Service Requested NU           Not Used Family Planning (unshaded area) Not Required
24I	ID Qualifier	Not Required
24J	Rendering Provider ID #	Required	In the shaded portion of the field, enter the eight-digit Colorado Medical Assistance Program provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.

CMS Field #	Field Label	Field is?	Instructions
			NOTE: When billing a paper claim form, do not use the individual’s NPI.
25	Federal Tax ID Number	Not Required
26	Patient’s Account Number	Optional	Enter information that identifies the patient or claim in the provider’s billing system. Submitted information appears on the Provider Claim Report (PCR).
27	Accept Assignment?	Required	The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer’s program.
28	Total Charge	Required	Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29	Amount Paid	Conditional	Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30	Reserved for NUCC Use
31	Signature of Physician or Supplier Including Degrees or Credentials	Required	Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent. A holographic signature stamp may be used if authorization for the stamp is on file with the fiscal agent. An authorized agent or representative may sign the claim for the enrolled provider if the name and signature of the agent is on file with the fiscal agent.

CMS Field #	Field Label	Field is?	Instructions
			Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014. Unacceptable signature alternatives: Claim preparation personnel may not sign the enrolled provider’s name. Initials are not acceptable as a signature. Typed or computer printed names are not acceptable as a signature. “Signature on file” notation is not acceptable in place of an authorized signature.
32	32- Service Facility Location Information 32a- NPI Number 32b- Other ID #	Not Required	Complete for services provided in a hospital or nursing facility in the following format: 1st Line     Name 2nd Line    Address 3rd Line    City, State and ZIP Code 32a- NPI Number Enter the NPI of the service facility (if known). 32b- Other ID # Enter the eight-digit Colorado Medical Assistance Program provider number of the service facility (if known). The information in field 32, 32a and 32b is not edited.
33	33- Billing Provider Info & Phone # 33a- NPI Number 33b- Other ID #	Required	Enter the name of the individual or organization that will receive payment for the billed services in the following format: 1st Line    Name 2nd Line    Address 3rd Line    City, State and ZIP Code 33a- NPI Number Not Required 33b- Other ID # Enter the eight-digit Colorado Medical Assistance Program provider number of the individual or organization.