WHG Helps Clients Understand  and Navigate the Convoluted HCPCS Coding Pathways​ and Application Processes 

  • 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.
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
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  • Level I of the HCPCS is comprised of Current Procedural Terminology (CPT-4) , a numeric coding system maintained by the American Medical Association (AMA). The CPT-4 is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. These health care professionals use the CPT-4 to identify services and procedures for which they bill public or private health insurance programs. Level I of the HCPCS, the CPT-4 codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.​
  • Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items.

Our innovative approach to ​HCPCS Coding Consulting is Built on a Two-Step Sequential Process:

  1. A core set of essential strategy analytics 
  2. Focused reimbursement pathways ​
​Critical to HCPCS Coding Success:
  • Coding applications are time sensitive, rigid and require expertise to help avoid rejections and/or miss categorized benefits, coding, coverage and payment decisions. ​
  • Good science and the ability to articulated and demonstrate cost effective clinical outcomes is a critical component to achieving a successful HCPCS coding, coverage and payment result.​
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.
  • Clients can miss critical analytics at the beginning of the 7-step reimbursement process focusing first on coding, then coverage and payment.  
  • Coding, coverage and payment pathways first require site of care specific, defined benefit categories.
  • Clients frequently encounter denials because of site of care or benefit category issues.
​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.
  • Policy clarification
  • Benefit manual revision
  • Coding modification
  • Coverage expansion
  • Payment revaluation
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:
  • Policy Clarification – Less formal instrument to expanded coverage criteria
  • Benefit Manual Revision – Subject to legislative language interpretation and clarification
  • Coding Modification – New code, descriptor modification, code verification
  • Coverage Expansion – More formal evidence based route to expanded coverage criteria in the form of an NCD, LCD and policy article
  • Payment Revaluation – Update pre-set data points, multi-layered variables and complicated formulas utilized to calculate fee schedules and prospective payment rates​​
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​