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Healthcare Common Procedure Coding System (HCPCS) Fraud

The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). CPT codes is a uniform coding system consisting of descriptive terms and identifying codes that are used to primarily identify medical services and procedures furnished by physicians and other health care professionals. These health care professionals use CPT codes to identify services and procedures for which they bill public or private health insurance programs. 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 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 codes, the level II HCPCS codes were established for submitting claims for these items. Upcoding and duplicate coding are common when fraud occurs with HCPCS Codes.

See Upcoding in this Glossary.

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