HCPCS Codes

HCPCS, pronounced "hick-picks," is the coding system that covers what CPT codes do not. CPT codes describe what a doctor does. HCPCS Level II codes describe the things used along the way: drugs given in a clinic or hospital, durable equipment like walkers and CPAP machines, ambulance trips, supplies, and some services Medicare needed a code for. They are one letter followed by four numbers. The J-codes for injected and infused drugs are the ones most people run into.

Here is why they matter to your wallet. A drug given by infusion is not billed as a prescription; it is billed as a J-code on a medical claim, and the price is whatever the facility and the plan negotiated for that code. Remicade, J1745, is billed per 10 milligrams, and a single infusion for an adult might be 40 units. At a hospital outpatient department the negotiated price per unit can be three to five times what an independent infusion center charges for the identical vial. I've seen the same drug, same dose, same patient, billed at $3,400 at a freestanding center and $14,000 at a hospital across town. The code was the same. Only the building changed. HCPCS codes also carry the ambulance charges (A0425 to A0436) that produce some of the worst surprise bills in the country.

The takeaway: if you are on an infused or injected specialty drug, get the J-code and units from your doctor and ask what each site charges for it. Moving an infusion out of the hospital is one of the largest single savings available to a family or an employer plan.