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IMPORTANT NOTE TO ALL HEALTH CARE PROVIDERS
The scheduled compliance date for all health care providers for the HIPAA Electronic Transactions Standards is October 16, 2002. The DHHS offered a one year extention to all health care providers if an application was submitted by Oct 15, 2002. If you did not complete and submit the extention application on time, you are expected to be compliant by October 16, 2002.
HIPAA Code Sets
Under the new Transaction Standards, you will be prohibited from using diagnosis and procedure codes that are not part of the standard set under HIPAA. The premise of these new rules is to ensure the computers in your office speak the same language as the computers at the health plan. The Transaction Standards require electronic transactions to be in a single common format - the ANSI ASC X12N (American National Standard's Institute's Accredited Standards Committee X12) format. Health care claims (including "encounter" claims), claims payment and remittance advice transactions, claims status inquiries, eligibility and benefits inquiries, and referral and authorization requests will use the ANSI X 12 standard formats when submitted electronically.

Fortunately, you can comply with HIPAA's Transaction Standards by either upgrading your practice management system to use the new standards, or you may submit your transactions to a health care claims clearinghouse to translate your existing information into HIPAA compliant formats. The clearinghouse in turn submits the information to the health plan. The final rule on HIPAA transaction standards allows both health care providers and health plans to continue using non-standard formats if they use a clearinghouse as an intermediary to translate non-standard formats into standard formats. Of course, you may always choose not to conduct your transactions on-line to avoid HIPAA's transaction standards requirements.

If you don't already know the particular data elements that make up each of the standard formats for these transactions, you may request copies of the implementation specifications for a standard (identifying the standard by name, number, and version) from the Washington Publishing Company, PMB 161, 5284 Randolph Road, Rockville, MD, 20852-2116; telephone 301-949-9740; and FAX: 301-949-9742. They are also available through the Washington Publishing Company on the Internet. You can locate the Washington Publishing Company through the CAL HIPAA web site in the Regulations Section at this URL: /main/hipaa_regs8code_sets.shtml

The details of the HIPAA Transaction Standards are explicitly defined in each guide, including data elements required or conditionally required, definitions of each data element, technical transaction formats for the transmission of the data, and code sets or values that can appear in selected data elements. Two more transactions, the "first report of injury" and "claims and other attachments" transactions, await completion of an implementation guide and should be finalized in the near future.

The explicitly defined data elements need to be "filled" with standardized data from HIPAA prescribed code sets. Industry de facto standards have been adopted for the coding of medical data elements, such as diagnoses, procedures, and drugs. These sets are the same sets currently mandated for use in Medicare and Medicaid documentation. Because of the widespread use of these "standards," they have been adopted by ASC X12N and the National Council for Prescription Drug Programs (NCPDP) and included in the HIPAA standards. You will likely recognize the following required code sets:
  • ICD-9-CM (vol. 1 & 2) Diseases, injuries, impairments, other health related problems, their manifestations, and causes of injury, disease, impairment, or other health-related problems.

  • CPT, CDT, or ICD-9-CM (vol. 3) Procedures or other actions taken to prevent, diagnose, treat, or manage diseases, injuries and impairments.

  • NDC - drugs.

  • HCPCS - Other health related services, other substances, equipment, supplies, or other items used in health care services.

As mentioned, HIPAA will prohibit health plans, including Medicare and Medicaid, from using unique and different diagnosis and procedure codes. Unique local codes currently used by the Medicaid program and other health plans will no longer be valid after the compliance date. Instead, plans must accept transactions that use the standard ICD-9-CM, CPT-4 HCPCS, and NDC (National Drug Codes) diagnosis and procedure codes used routinely by physicians today. The Washington Publishing Company's web site contains transaction implementation guides, data conditions, and the data dictionary for the X12N standards. It can be found in the below Resources for Standard Code Sets.
HIPAA Compliance Dates
Standard Compliance Date Extention Date
Transactions and Code Sets 10/16/2003 10/16/2003
Only if application filed
before Oct 15, 2002.
National Provider Identifier Pending Not Applicable
National Employer Identifier Pending Not Applicable
Security Rule 4/20/2005 Not Applicable
Privacy Rule 4/14/2003 Not Applicable
National Health Plan identifier Pending Not Applicable
Claims Attachments Pending Not Applicable
Enforcement Pending Not Applicable
National Individual Identifier Pending Not Applicable
Code Sets Resources
Below is a list of resources for many of the standard code Sets
with links to the web sites where they can be obtained.
Code Code Set Available From Status
4 ABA Routing Number Thomson Financial Publishing Available for Purchase
5 Countries -ISO 3166 American National Standards Institute (ANSI) - ISO 3166 Available for Purchase
    Countries -ISO 3166 ISO 3166 Maintenance Agency Unrestricted Access
    Currencies and Funds - ISO 4217 American National Standards Institute (ANSI) ISO 4217 Available for Purchase
    Currencies and Funds - ISO 4217 BSI Currency Code Service Unrestricted Access
16 D-U-N-S Number Dun & Bradstreet Available for Purchase
22 States and Outlying Areas of the U.S. U.S. Postal Service Unrestricted Access
41 Universal Product Code Uniform Code Council, Inc. Unrestricted Access
51 ZIP Code U.S. Postal Service Unrestricted Access
60 BFI Identification Number Thomson Financial Publishing Available for Purchase
77 X12.3 Data Element Dictionary/X12.22 Segment Directory Data Interchange Standards Association, Inc. (DISA) Available for Purchase
91 Canadian Financial Institution Branch and Institution Number Bowne of Canada,Ltd Available for Purchase
94 International Organization for Standardization (Date and Time) American National Standards Institute (ANSI) - ISO 8601 Available for Purchase
102 Languages American National Standards Institute (ANSI) - ISO 639 Available for Purchase
121 Health Industry Identification Number Health Industry Business Communications Council Restricted Access
130 HCPCS - 2001 CMS Available for Purchase
131 ICD-9-CM U.S. National Center for Health Statistics Unrestricted Access/Available for Purchase
132 National Uniform Billing Committee (NUBC) Codes National Uniform Billing Committee Available for Purchase
133 CPT Codes Order Department (AMA) Available for Purchase
134 National Drug Code U.S. Food and Drug Administration (FDA) Unrestricted Access
135 American Dental Association Codes (CDT-3) American Dental Association Available for Purchase
139 Claim Adjustment Reason Codes Washington Publishing Company Unrestricted Access
158 Health Care Financing Administration (HCFA) - Code Lists CMS Unrestricted Access
229 Diagnosis Related Group Number (DRG) Superintendant of Documents - US Government Printing Office Unrestricted Access/Available for Purchase
230 Admission Source Code National Uniform Billing Committee Available for Purchase
231 Admission Type Code National Uniform Billing Committee Available for Purchase
235 Claim Frequency code National Uniform Billing Committee Available for Purchase
236 Uniform Billing Claim Form Bill Type National Uniform Billing Committee Available for Purchase
237 Place of Service CMS Unrestricted Access
239 Patient Status Code National Uniform Billing Committee Available for Purchase
240 National Drug Code by Format Federal Drug Listing Branch HFN-315 Unrestricted Access
245 National Association of Insurance Commissioners (NAIC) Code National Association of Insurance Commissioners Available for Purchase
307 National Association of Boards of Pharmacy Number National Council for Prescription Drug Programs Available for Purchase
359 Treatment Codes CMS Unrestricted Access
411 Remittance Remark Codes Washington Publishing Company Unrestricted Access
457 NISO Z39.53 Language Code List National Information Standards Organization Press Unrestricted Access
507 Health Care Claim Status Category Code Washington Publishing Company Unrestricted Access
508 Health Care Claim Status Code Washington Publishing Company Unrestricted Access
513 Home Infusion EDI Coalition (HEIC) Code List Home Infusion EDI Coalition Unrestricted Access
530 National Council for Prescripton Drug Programs Reject/Payment Codes NCPDP Available for Purchase for Non Members/Unrestricted Access for Members
537 Health Care Financing Administration National Provider Identifier CMS Unrestricted Access
540 Health Care Financing Administration National PlanID CMS Unrestricted Access
    HCFA Public Use Files CMS Unrestricted Access
    Provider Taxonomy Codes Washington Publishing Company Unrestricted Access
    Canadian Province Abbreviations Canadian Postal Service Unrestricted Access/Available for Purchase
    CLIA Number CMS Unrestricted Access
    NUBC Condition Codes National Uniform Billing Committee Available for Purchase
    NUBC Occurrence Codes National Uniform Billing Committee Available for Purchase
    NUBC Occurrence Span Codes National Uniform Billing Committee Available for Purchase
    NUBC Value Codes National Uniform Billing Committee Available for Purchase
    UB92 Bill Type Code National Uniform Billing Committee Available for Purchase
    UB92 Facility Type Code (2 digits) National Uniform Billing Committee Available for Purchase
    UB92 Revenue Codes National Uniform Billing Committee Available for Purchase
    IHS/CHS Tribal Residency Codes Indian Health Service Unrestricted Access
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