C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-5, subsec. 144-101-III-5.04

Current through 2024-46, November 13, 2024

Subsection 144-101-III-5.04 - ELEMENTS OF HCPCS CODING

HCPCS codes for services are arranged in tabular form. Specific information regarding each code is given under the following headings:

1.Procedure Code The actual HCPCS procedure code will be listed in this column.

2.HCPCS Description The narrative description of the procedure will appear here along with any age restrictions.

3.Maximum Allowance This column will show the maximum reimbursement MaineCare will allow for a particular procedure. Please remember that MaineCare pays the lowest of the usual and customary charge, the Medicare maximum rate, or the MaineCare maximum allowance.

4.Prior Authorization Some procedures require prior authorization in order for MaineCare to allow payment. If prior authorization is required, it will be indicated by the message "Yes" in this column.

5.Modifier Required Add two-letter modifier as a suffix to codes (origin/destination). Codes that require modifier will be indicated by the message "yes" in this column.

Not all procedures are reimbursable in every setting. If you have a question as to whether or not a particular service can be rendered in a particular setting, please consult Chapter II, Section 5 of the MaineCare Benefits Manual or contact your Provider Relations Specialist.

General The procedure codes and descriptions for Ambulance Services as listed below are to be used in completing the CMS 1500 Claim Form.

Please Note: Where Departmental review indicates charges and payments in excess of the Medicare Part B allowed amount at the time of service delivery, the Department will seek restitution for any payments that exceed the Medicare allowance.

C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-5, subsec. 144-101-III-5.04