Chapter 4

1. HIPAA for Allied Health Careers Chapter 4 The HIPAA Transactions, Code Sets, and National Standards

2. LEARNING OUTCOMES After studying this chapter, you should be able to: State the purpose of the HIPAA Electronic Health Care Transactions and Code Sets standards and of the national identifiers. Name eight HIPAA transactions. Identify the key purpose of the Administrative Simplification Compliance Act. List the HIPAA standards for medical code sets. Compare and contrast the ICD-9-CM diagnosis codes, CPT and HCPCS procedure and supply codes, and ICD-9-CM Volume 3 procedure codes. Describe the sources for up-to-date information on changes to the HIPAA medical code sets for diagnoses and procedures. Discuss the general purpose of the HIPAA-mandated administrative code sets. Describe the sources for up-to-date information on changes to the HIPAA administrative code sets. Describe the HIPAA Employer Identifier standard. Describe the HIPAA National Provider Identifier standard.

3. 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 Key Terms

4. 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 KEY TERMS (cont’d)

5. 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 Key Terms (cont’d)

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

7. Eight HIPAA Transactions (+ ninth pending approval) Health plan premium payments Enrollment or disenrollment in a health plan Eligibility Referral certification and authorization Claims Payment with an explanation Claim status Coordination of benefits Claim attachments Transaction Standards

8. 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 Transactions Standards (cont’d)

9. 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. Transaction Standards (cont’d)

10. 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 Transaction Standards (cont’d)

11. 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 Transaction Standards (cont’d)

12. 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. Medical Code Sets

13. 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: Category I codes are procedure codes. Category II codes are performance measures of a medical goal. Category III codes are temporary codes. Medical Code Sets (cont’d)

14. ICD-9-CM Volume 3: Codes for Hospital Inpatient Procedures and Services Remember: Diseases and Injuries: Tabular List—Volume 1 Diseases and Injuries: Alphabetic Index—Volume 2 3. Procedures: Tabular List and Alphabetic Index—Volume 3 Medical Code Sets (cont’d)

15. 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. Medical Code Sets (cont’d)

16. 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. Medical Code Sets (cont’d)

17. 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. Administrative Code Sets

18. 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. Administrative Code Sets (cont’d)

19. 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. Administrative Code Sets (cont’d)

20. 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. HIPAA National Identifier Standards