I recently completed a consulting project for a client that required researching commercial payer coverage policies for a specific procedure. What I found was that, in addition to a list of relevant CPT codes for the particular service I was researching, there was a host of HCPCS “S” codes that were included in some of the coverage policies. It occurred to me that these are not codes you come across every day, so I took the opportunity to refresh my understanding of these codes. I’ll share with you what I learned.
If you review the current list of HPCPCS “S” codes (available in the Coding Suite via the HCPCS and CPT Codebook) you will notice that the S codes represent a wide variety of items and services, including drugs, supplies, and services. You may be wondering: How are these codes different from other HCPCS and CPT codes? How and why were they assigned? Who uses them?
While HCPCS and CPT were designed as code sets intended to be used nationally by all payers, there are some situations where a commercial payer may deem the existing codes inadequate to describe an item or service. In these cases, the payer may request assignment for a code to identify the item or service. These codes are HCPCS “S” codes. “S” codes are national, non-Medicare codes that may be used by commercial insurance companies such as Blue Cross-Blue Shield and by state Medicaid agencies. The codes are assigned by the HCPCS Workgroup, which consists of representatives from private insurance companies, Medicaid, and the Pricing, Data Analysis and Coding Contractor (PDAC, a Medicare entity). These codes are not reportable to Medicare.
Something interesting that I noticed is that in the case of some “S” codes, the procedure is otherwise reportable with CPT codes. For example, there are “S” codes for breast cancer gene testing (BRCA1 and BRCA2). However, this testing is also reportable with existing CPT codes with a genetic modifier appended. The difference is that reporting with CPT codes requires reporting each component of the diagnostic test (e.g. isolation of nucleic acid, amplification, mutation identification etc.), whereas the “S” code captures all components of the procedure. When multiple means of reporting the same procedure exist, we must refer to the payer’s policy to determine how the procedure should be reported.
The take-home message is that it’s not always enough to look in the “usual” places when you’re looking for the appropriate code to report an item or service. When in doubt, take a look at the payer’s coverage policy, and maybe peruse the “S” code list.
Written by: Beth Browne, RN, MSN, NP, CCS