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Chapter 4

The HIPAA Transactions,

Code Sets, and National Standards

HIPAA for

Allied Health Careers

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LEARNING OUTCOMESAfter studying this chapter, you should be able to:

1. State the purpose of the HIPAA Electronic Health Care Transactions and Code Sets standards and of the national identifiers.

2. Name eight HIPAA transactions.3. Identify the key purpose of the Administrative Simplification Compliance

Act.4. List the HIPAA standards for medical code sets.5. Compare and contrast the ICD-9-CM diagnosis codes, CPT and HCPCS

procedure and supply codes, and ICD-9-CM Volume 3 procedure codes.6. Describe the sources for up-to-date information on changes to the HIPAA

medical code sets for diagnoses and procedures.7. Discuss the general purpose of the HIPAA-mandated administrative code

sets.8. Describe the sources for up-to-date information on changes to the HIPAA

administrative code sets.9. Describe the HIPAA Employer Identifier standard.10. Describe the HIPAA National Provider Identifier standard.

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Key Terms

• administrative code sets• Administrative Simplification Compliance Act (ASCA)• ASC X12• claim adjustment reason codes (RC)• claim attachment• claim status category codes• claim status codes• code set• Current Dental Terminology (CDT)• Current Procedural Terminology (CPT)• Designated Standard Maintenance Organization (DSMO)• 820 Health Plan Premium Payments

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KEY TERMS (cont’d)

• 834 Health Plan Enrollment and Disenrollment• 835 Health Care Payment and Remittance Advice • 837 Health Care Claims or Equivalent Encounter

Information/Coordination of Benefits • EIN (Employer Identification Number) Health Care Common

Procedure Coding System (HCPCS)• HIPAA Electronic Health Care Transactions and Code Sets (TCS) • HIPAA Employer Identifier• ICD-10-CM• implementation guide• International Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM)• legacy identifiers• medical code sets

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Key Terms (cont’d)

• National Plan and Provider Enumeration System (NPPES)• National Provider Identifier (NPI)• 997 Functional Acknowledgment• place of service (POS) code• remittance advice (RA)• remittance advice remark codes (REM)• taxonomy codes• 270/271 Eligibility for a Health Plan Inquiry/Response• 276/277 Health Care Claim Status Inquiry/Response

• 278 Referral Certification and Authorization

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HIPAA Electronic Health Care Transactions, Code Sets, and National Identifiers

• Standard Transactions– A standard transaction involves the transfer of ePHI.– All such transactions must comply with HIPAA standards.

• Standard Code Sets– Code sets are a group of codes used for encoding data.– Medical code sets are for diagnoses, treatments, and supplies

used in treatments.– Administrative code sets capture administrative information

• National Identifiers– HIPAA-mandated national numbers for employers, health care

providers, health plans, and patients.

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Transaction Standards

• Eight HIPAA Transactions (+ ninth pending approval)1. Health plan premium payments2. Enrollment or disenrollment in a health plan3. Eligibility4. Referral certification and authorization5. Claims6. Payment with an explanation7. Claim status8. Coordination of benefits9. Claim attachments

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Transactions Standards (cont’d)

• Numbers and names of standards– 820 Health Plan Premium Payments– 834 Health Plan Enrollment and Disenrollment – 270/271 Eligibility for a Health Plan Inquiry/Response– 278 Referral Certification and Authorization– 837 Health Care Claims or Equivalent

Encounter Information/Coordination of Benefits – 275 Additional Information to Support a Health

Care Claim or Encounter (Claim Attachment; pending approval)

– 276/277 Health Care Claim Status Inquiry/Response – 835 Health Care Payment and Remittance

Advice

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Transaction Standards (cont’d)

• What Do the Transactions Cover?– 820 Health Plan Premium Payments covers proper application of premium

payments.– 834 Health Plan Enrollment and Disenrollment covers whether or not a member

is eligible for benefits.– 270/271 Eligibility for a Health Plan Inquiry/Response provides way to determine

if a particular service is covered for a patient.– 278 Referral Certification and Authorization determines whether

preauthorization is needed.– 837 Health Care Claims or Equivalent Encounter Information/Coordination of

Benefits covers primary and secondary insurance.– 275 Additional Information to Support a Health Care Claim or Encounter (Claim

Attachment; pending approval) covers requests for more detailed information.– 276/277 Health Care Claim Status Inquiry/Response provides information about

the status of a claim and if more information is needed.– 835 Health Care Payment and Remittance Advice covers the payment and the

details of the payment decision.

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Transaction Standards (cont’d)

• Who Must Comply?– Administrative Simplification Compliance Act—all Medicare

claims must be submitted electronically except:• A small provider (fewer than ten full-time employees)• A dentist• A participant in a Medicare demonstration project• A provider that conducts mass immunizations• Home oxygen therapy claims (under certain conditions)• A provider that submits claims when more than one other

payer exists• A provider of services outside the United States only• A provider with disruption in electricity and/or

communications• An “unusual circumstance,” which can be established

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Transaction Standards (cont’d)

• Who Must Comply? (cont’d)– Implementation Guides are available for each standard.– Designated Standard Maintenance Organizations (DMSOs)

• Accredited Standards Committee X12• Dental Content Committee of the American Dental

Association• Health Level Seven• National Council for Prescription Drug Programs• National Uniform Billing Committee• National Uniform Claim Committee

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Medical Code Sets

• ICD-9-CM (Volumes 1 and 2): Codes for Diseases– Three-, four-, or five-digit codes that categorize diseases, injuries, and

symptoms– Updates take effect April 1 and October 1 of every year.

• ICD-10-CM– Published by WHO in 1990. Expected to be adopted universally.– Major changes:

• ICD-10 contains more than two thousand categories of diseases.• Codes are alphanumeric, containing a letter followed by up to five

numbers.• A sixth digit is added to capture clinical details.• Codes are added to show which side of the body is affected.

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Medical Code Sets (cont’d)

• CPT: Codes for Physician Procedures and Services– Current Procedural Terminology (CPT) produced and

owned by AMA.– Lists procedures and services performed by

physicians.– Three categories of CPT codes:

1. Category I codes are procedure codes.2. Category II codes are performance measures of a

medical goal.3. Category III codes are temporary codes.

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Medical Code Sets (cont’d)

• ICD-9-CM Volume 3: Codes for Hospital Inpatient Procedures and Services

• Remember:1. Diseases and Injuries: Tabular List—Volume 1

2. Diseases and Injuries: Alphabetic Index—Volume 2

3. Procedures: Tabular List and Alphabetic Index—Volume 3

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Medical Code Sets (cont’d)

• HCPCS: Codes for Other Supplies and Services

– Healthcare Common Procedure Coding System (HCPCS) for products, supplies, and services not in CPT

– Five characters beginning with a letter.

– Codes released every January 1.

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Medical Code Sets (cont’d)

• CDT: Codes for Dental Procedures

– Current Dental Terminology (CDT) published by ADA.

– Five-digit codes beginning with the letter D.

• NDC: Codes for Drugs

– National Drug Codes (NDC) used only by retail pharmacies.

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Administrative Code Sets

• Claim Status Category Codes and Claim Status Codes – Claim status category codes

• A codes are an acknowledgment that the claim has been received.

• P codes indicate that a claim is pending.• F codes indicate that a claim has been finalized.• R codes indicate that a request for more information has

been sent.• E codes indicate that an error has occurred in transmission.

– Claim status codes are further details of the claim status category codes.

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Administrative Code Sets (cont’d)

• Claim Adjustment Reason Codes

– Abbreviated RC.– Details why payment differs from amount billed.

• Remittance Advice Remark Codes

– Abbreviated REM.– Gives further details about reason codes.

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Administrative Code Sets (cont’d)

• Health Care Provider Taxonomy Code Set

– Taxonomy code is a ten-digit number standing for a physician specialty.

– Maintained by the National Uniform Claim Committee (NUCC).

• Place of Service Codes (POS)

– Two-digit codes indicating setting of service, such as 11 office or 21 inpatient hospital.

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HIPAA National Identifier Standards

• Employer Identification Number (EIN)– Issued by IRS to employers.

• National Provider Identifier (NPI)– Issued by federal government to all providers.

• National Plan and Provider Enumeration System (NPPES)– Assigns and maintains all NPIs for both health plans

and providers.