WHG Helps Clients Develop Targeted HCPCS Coding Strategies and Execute HCPCS Application Processes to Help Maximize Stakeholder Value
HCPCS Coding is the second most critical factor of the 7-reimbursement components
- Beginning with diagnosis, treatment plan, site of care, and benefit category to coding, coverage and payment.
- Benefit category is the most critical – without a benefit category CMS is prohibited from assigning coding, coverage and payment for any potential Level I or Level II procedure, product or service.
- WHG HCPCS consulting includes working with CMS to first confirm a defined benefit category.
Why Choose WHG
- WHG understands the nuances of the complex HCPCS Level I and Level II coding pathways.
- WHG provides strategy analytics and reimbursement pathways based on real-life successful HCPCS coding track record.
- WHG is strategically located on Pennsylvania Avenue between the Capitol and the White House and just six blocks for the main HHS building. Because of our location, WHG has been able, pre-pandemic, to more readily access face-to-face meetings at multiple levels of the HHS Agencies and on Capitol Hill.
- WHG is a known entity because of previous years Washington D.C. presence, participating in face-to-face meetings at multiple levels of the HHS Agencies and on Capitol Hill. As a known entity and WHG knows how to leverage virtual access to key decision-makers at the HHS Agencies and on Capitol Hill.
- WHG is a member of the HCPCS Coding Reform Alliance. The Alliance is advocating for transparency, and separation of the coverage and coding process, among other problematic issues.
- Deb Wells has been recognized for her participation in the CMS HCPCS New Coding Application Beta testing and the HCPCS Coding Reform Alliance.
HCPCS level I or HCPCS Level II Pathway - Not Always a Clear Cut Choice!
The Healthcare Common Procedure Coding System (HCPCS) is divided into two principal subsystems, referred to as Level I and Level II of the HCPCS.
- Level I - CPT-4 is maintained by the AMA
- Level II - Alpha Numeric is maintained by CMS
Our innovative approach to HCPCS Coding Consulting is Built on a Two-Step Sequential Process:
Critical to HCPCS Coding Success:
WHG's comprehensive reimbursement and market pathways are founded on 70+ years healthcare industry and government relations experience.
Each of the four (4) legislated Medicare insurance plans, (Part A, B, C, & D) covers different healthcare-related costs and pays for these well-defined services utilizing twenty (20) complicated fee-for-service and prospective payment systems.
Health Policy Challenges that Affect Reimbursement and Market Access
New FDA Emergency Use Authorization (EUA) regulations to allow for unapproved medical products or unapproved uses of approved medical products to be used in an emergency.
FDA approval and FDA clearance for non EUA medical products allows for commercialization. It does not mean that a product is covered or eligible for reimbursement by Medicare, Medicaid, or commercial insurance.
FDA approved indications for use and FDA product coding can result in downstream consequences with significant reimbursement pathway implications.
FDA controlled regulations affect CMS controlled policies determining site of care utilization, benefit category, coverage criteria and payment mechanisms.
Establishing new IPPS/HCPCS/CPT codes does not equate to CMS coverage or adequate payment, these reimbursement steps are separate CMS processes.
FDA regulations and CMS reimbursement processes are not intuitive and can lead to uncertainties and market access complications
Critical WHG Strategy Analytics - Prior to Submitting HCPCS Applications
Comprehensive Medicare, Medicaid and commercial insurance reimbursement pathway analysis.
Guidance through all 7-reimbursement steps - from diagnosis, treatment plan, site of care, and benefit category to coding, coverage and payment.
CMS utilization, mean costs and crosswalk data analytics are fundamental metrics of HHS and CMS decision-making trends.
CPT-RVU build up analysis - primary foundation of the annual Medicare Physicians Fee Schedule (MPFS) Rule Making process.
WHG categorizes the foundation of the hurdles identified in the 7-step reimbursement analysis and CMS analytics - executable milestones.
WHG identifies the current political and policy landscape
- Who can influence the change?
- What is the appetite for change?
Strategy analytics is the foundation for developing reimbursement pathways
WHG Focused Reimbursement Pathways
We identify the foundation of reimbursement hurdles or opportunities and prioritize executable milestones to maximize reimbursement:
We determine the pathway tactics once the actionable reimbursement strategies are defined and prioritized:
- Determine HHS and CMS policy jurisdiction
- Outline HHS and CMS decision-making processes
- Identify HHS and CMS key decision-makers and influencers
- Determine Capitol Hill policy jurisdiction, appropriations and oversight responsibilities
- Identify Capitol Hill key decision-makers and influencer
Are you Prepared for value-based payments? In the absence of evidence lower cost pressures will always prevail