When you want to know how much a medical procedure may cost, it’s common to just think about the service itself. But medical care has a lot of moving parts, and those parts can add up quickly. When you have your appendix removed, you or your insurer will have to pay the surgeon’s and anesthesiologist’s fees. But you’ll also need to pay for the scalpels, needles, bandages, gauze, and medications that were used during your surgery. These supplies, drugs and equipment may be listed on your bill or Explanation of Benefits, using a standard code called HCPCS (sometimes pronounced “hick picks”).
Why is it important to understand HCPCS codes? First, it will help you get a better sense of the full cost of your care. Sometimes, you can plan in advance to help manage your costs. You also can make sure that you or your insurance company pays only for the supplies and equipment that you actually received.
What are HCPCS codes?
Each HCPCS code represents a specific item, and helps insurers to understand what medical supplies or equipment you received. Providers include these codes when they submit claims to your insurer. Then, your insurer generally uses the code to determine how much to pay. HCPCS codes can show items like:
There are thousands of HCPCS codes. You can recognize a HCPCS code on your bill or Explanation of Benefits form because it starts with a letter, followed by four numbers (for example, Q2035 for a flu vaccine, or E0110 for a pair of crutches). If your doctor bandaged a wound, there will be a HCPCS code for the cost of the bandage. Like CPT codes, a HCPCS code will sometimes be followed by two extra letters or numbers. This is a “modifier” that gives the insurer more information. For example, if your doctor applied a dressing to multiple wounds, there may be a modifier after the code to tell your insurer how many wounds were bandaged. If you received diabetic supplies, there might be a modifier after the code to tell your insurer whether the supplies were ordered and received from a drug store or a mail-order supplier. For more information on modifiers, see Claim Modifiers: What Are They and How Do They Affect Me.
How Can I Use HCPCS Codes?
Understanding HCPCS codes can help you plan your costs when you need care. Some costs are unavoidable, like bandages and surgical supplies. But if you are having an elective procedure, like knee surgery, first ask your doctor what supplies and equipment you will need after the surgery. Then, check your health plan description or talk to your insurer about what is covered. Will your plan pay for a knee brace, and crutches? Are there certain types of supplies you will need, and will you need to get them from a specific company?
If your plan doesn’t cover some equipment, or if you are using a provider outside your network, you can ask your doctor about ways to lower your costs. It may be less expensive to rent a breast pump than to buy one, for example. You also can check FAIR Health’s Cost Estimator to find out what these supplies typically cost in your area.
After you get care, it’s good practice to look at all the codes listed on your bill or claim form. Remember, doctors, hospitals, ambulatory surgical centers, pharmacies and medical equipment providers, and insurers can make mistakes. You don’t need to be a claims specialist. Just a basic understanding of how these codes work can help you ask the right questions. If you see a code that is wrong – like a charge for a flu shot that you didn’t receive – ask your provider to
correct it and send an adjusted claim to your insurer.
If you used an out-of-network provider and the costs seem high, you also can use FAIR Health’s Cost Estimator. If your doctor, facility, or durable medical equipment provider charged much more than the usual cost in your area, you can try to negotiate a lower price.
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