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Minnesota AUC Administrative Simplification
 

Code Sets

Overview:

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a "code set" is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes.

Medical data code sets that are used in the health care industry include coding systems for: diseases, injuries, impairments, other health related problems, and their manifestations; causes of injury, disease, impairment, or other health-related problems; actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments and any substances, equipment, supplies, or other items used to perform these actions. Code sets for medical data are required for data elements in administrative and financial health care transaction standards adopted under HIPAA for diagnoses, procedures, and drugs.

Specifics:

The administrative simplification provisions of HIPAA require the Secretary of DHHS to adopt standards for code sets for administrative and financial transactions. Two types of code sets are required for data elements in the transaction standards to be established under HIPAA.

Large code sets for medical data, including coding systems for:
  • diseases, injuries, impairments, other health related problems, and their manifestations.
  • causes of injury, disease, impairment, or other health-related problems.
  • actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments and any substances, equipment, supplies, or other items used to perform these actions.
Smaller sets of codes for other data elements such as:
  • race/ethnicity.
  • type of facility.
  • type of unit.
The code sets being proposed as initial HIPAA standards are standards already in use by most health plans, health care clearinghouses, and health care providers. They are:

ICD-9-CM: The International Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM),classifies both diagnoses (Volumes 1 & 2) and procedures (Volume 3). All hospitals and ambulatory care settings use this classification to capture diagnoses for administrative transactions. The ICD-9-CM procedure system is used for all inpatient procedure coding for administrative transactions.

CPT-4: Physician Current Procedural Terminology (CPT) is used by all physicians to code their services for administrative transactions. CPT-4 is level one of the Health Care Financing Administration Procedure Coding System (HCPCS).

Alpha-numeric HCPCS: Alpha-numeric Health Care Financing Administration Procedure Coding System (HCPCS) contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT-4. Alpha-numeric codes are level 2 of HCPCS. They are used in ambulatory settings.

CDT-2: Current Dental Terminology (CDT) is used for reporting dental services. CDT-2 codes are also included in alpha-numeric HCPCS with a first digit of D.

NDC: National Drug Codes (NDC) are used for reporting prescription drugs in pharmacy transactions and some claims by health claim professionals.

Impact:

By adopting standards for code sets we are requiring that all parties accept these codes within their electronic transactions. We are not requiring payment for all services for which there are codes. However, when the HIPAA code set standards become effective, all health plans will have to receive and process all standard codes, regardless of reimbursement or coverage policies for certain conditions or procedures. The requirement to use standard coding guidelines will simplify claims submission for health care providers who deal with multiple health plans and improve data quality. Health plans and others that do not follow official coding guidelines today will be required to modify their systems to accept all valid codes in the standard or engage a health care clearinghouse to process the standard transactions for them.

Benefits:

Standardized data content is essential for accurate and efficient electronic data exchange between the many producers and users of administrative health care transactions. Currently, these national codes sets are mandated for use in some Federal and State programs, such as Medicare and Medicaid. The Accredited Standards Committee X12N and National Council for Prescription Drug Programs standards setting organizations have adopted these codes sets for use in their standards.

  
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