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HIPAA Simplified
Code Sets
The following code sets are used in the HIPAA named transactions. They are external to the transaction implementation guides and are maintained separately from the standards. Code sets can be obtained or purchased from the entity that maintains the code sets.
Code Set Regulations
Transactions and Code Sets
The Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice adopted by the Department of Health and Human Services (HHS) on August 17, 2000, named the following code sets for use in the standard transactions:
- Healthcare Common Procedure Coding System (HCPCS) - Ancillary Services/Procedures
- Current Procedural Terminology (CPT-4) - physician procedures
- Code on Dental Procedures and Nomenclature (CDT) - dental terminology
- ICD-9-CM (diagnosis) and ICD-9-PCS - hospital inpatient procedures
- National Drug Codes (NDC) - drug codes
The HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM and ICD–10–PCS Final Rule was adopted by HHS to move to the 10th edition of the ICD codes on October 16, 2003.
ICD-10
ICD-10 is the tenth revision of the International Statistical Classification of Diseases and Related Health Problems. The World Health Organization (WHO) manages the base code set; WHO members including the United States have modified the list to meet their needs.
The Department of Health and Human Services (HHS) published the HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM and ICD–10–PCS Final Rule on January 16, 2009 which required health care providers and health plans to utilize ICD-10-CM diagnosis codes and ICD-10-PCS inpatient procedure codes for dates of service or discharge on or after October 1, 2013.
On September 5, 2012, in the Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets Final Rule, the date was extended to October 1, 2014.
On April 1, 2014, H.R.4302 / Public Law 113-93, the Protecting Access to Medicare Act was signed into law stating that HHS could not adopt ICD-10 until at least October 1, 2015.
On August 4, 2014, HHS published its final extension in the Administrative Simplification: Change to the Compliance Date for the International Classification of Diseases, 10th Revision (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets Final Rule, which set the compliance date to October 1, 2015.
Maintenance Schedule: Annually - October
Related links:
- ICD-10-CM (Clinical Modification)
- ICD-10-PCS (Procedural Coding System)
- View the Original Legislation
- View the First Extension
- View the Final Extension
Claim Adjustment Reason Codes (CARC)
Claim Adjustment Reason Codes describe the reason for a payment adjustment relating to the adjudication of a health care claim.
Maintained by the Codes Maintenance Committee.
Maintenance Schedule: Three times per year (February, June, October)
CDT
Code on Dental Procedures and Nomenclature (CDT) codes are used to document dental treatment. CDT code set has been named as a HIPAA standard.
Maintained by the American Dental Association (ADA).
Maintenance Schedule: Annually - January
CPT-4
Current Procedural Terminology (CPT) codes are used for coding professional (physician and outpatient) procedures. The CPT code set has been named as a HIPAA standard.
Maintained by the American Medical Association (AMA).
Maintenance Schedule: Annually – January
Claim Status Category Code
Claim Status Category Codes describe the general category of a claim’s status (accepted, rejected, etc.)
Maintained by the Codes Maintenance Committee.
Maintenance Schedule: Three times per year (February, June, October)
ICD-10-CM
International Classification of Diseases, Tenth Revision, Clinical Modification
ICD-10-CM is the clinical modification of the World Health Organization’s ICD-10 diagnosis codes. The ICD-10-CM has been named as a HIPAA standard, replacing ICD-9 for all claims with dates of service on and after 10/1/2015 or for inpatient claims, with a date of discharge of 10/1/2015 or later.
Maintained by the National Center for Health Statistics (NCHS).
Maintenance Schedule: Annually – October.
ICD-10-PCS
International Classification of Diseases, Tenth Revision, Procedure Coding System
ICD-10-PCS is the United States’ clinical modification of the World Health Organization’s ICD-10 procedure coding system and used for coding hospital inpatient procedures. The ICD-10-PCS code set has been named as a HIPAA standard, replacing ICD-9 for all claims with dates of service on and after 10/1/2015 or for inpatient claims, with a date of discharge of 10/1/2015 or later.
Maintained by the Centers for Medicare & Medicaid Services (CMS).
Maintenance Schedule: Annually – October.
HCPCS
Healthcare Common Procedure Coding System (HCPCS) is used primarily to identify products, supplies, and services not included in the CPT code set, such as durable medical equipment, prosthetics, and ambulance services, HCPCS has been named as a HIPAA standard.
Maintained by the Centers for Medicare & Medicaid Services (CMS).
Maintenance Schedule: Annually – January, with quarter updates when needed.
Health Care Provider Taxonomy Codes
Health Care Provider Taxonomy Codes categorize the type, classification and/or specialization of health care providers.
Maintained by the National Uniform Claim Committee (NUCC).
Maintenance Schedule: Release July – Effective October, and January – Effective April
Health Care Review Decision Reason Codes
Health Care Review Decision Reason Codes describe the reason for the health service review outcome.
Maintained by the Codes Maintenance Committee.
Maintenance Schedule: Three times a year (February, June, October)
LOINC
The Logical Observation Identifiers Names and Codes (LOINC) is a universal standard used to assist in the electronic exchange and gathering of clinical information.
Maintained by the Regenstrief Institute.
NDC
National Drug Codes (NDC) identify the vendor (manufacturer), product and package size of all drugs and biologics recognized by the FDA.
Maintained by the U. S. Food and Drug Administration (FDA).
Maintenance Schedule: Daily
NUBC
The National Uniform Billing Committee (NUBC) code sets consist of the following codes used in or relating to health care claims:
- Type of Bill Codes – the type of facility and classification of the claim.
- Type of Bill Frequency Codes – sequence of a claim in the current episode of institutional care (for example, admit through discharge, interim billing).
- Priority (Type) of Admission Visit Codes – describes generally the priority of admission (for example, emergency, urgent).
- Point of Origin of Admission or Visit Codes – where the admission or visit originated from.
- Patient Discharge Status Codes – the disposition or discharge status of the patient at the point of billing.
- Condition Codes – conditions or events that may affect processing of the claim.
- Occurrence Codes - describe single occurrence dates used in the claim.
- Occurrence Span Codes – describe date spans used in the claim.
- Value Codes – describe values significant to the processing of a claim.
- Revenue Codes – identify accommodations, ancillary services, unique billing calculations, or arrangements relevant to the claim.
Maintained by the NUBC.
Maintenance Schedule: Three times a year (January, April, July)
Place Of Service Codes
Place of Service Codes describe the location where a service is rendered.
Maintained by the Centers for Medicare and Medicaid Services (CMS).
Maintenance Schedule: There is no fixed schedule for this code set.
Remittance Advice Remark Codes (RARC)
Remittance Advice Remark Codes are used to further describe (in addition to the Claim Adjustment Reason Code) the reason for an adjustment to a claim payment or to or convey information about remittance processing.
Maintained by the Centers for Medicare & Medicaid Services (CMS).
Maintenance Schedule: Three times a year (March, July, November)