CMS Pub. 100-04, ch. 23, § 20.8

HCPCS Codes Update File

(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)

The file CMS provides for the quarterly update of HCPCS codes contains fields for payment, UR, and

coverage information to assist in developing front-end edit screens. Coverage information is not all

inclusive, but should be used mainly as a guide in establishing specific review limits. A/B MACs (B) must

establish reasonable developmental guidelines, review screens, and relative value units, as appropriate. A/B

MACs (B) must assure that their system processes claims in accordance with CMS policies and procedures,

including changes that may occur between HCPCS codes updates.

Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement

policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as

Level II codes/modifiers prefixed with “Q” or “K” or “G.” Questions may arise in updating that require A/B

MAC (B) staff to refer to a physician’s or supplier’s pricing history. Therefore, keep an electronic backup

of HCPCS codes for the two prior years with linkages to pricing profiles. Perform required computer

analysis as necessary.

The HCPCS terminology seldom includes a place of service designation. Where place of service affects

pricing, pricing is obtained from the place of service field on the claim record.

A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage

policies from CMS. A/B MAC