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« Back HIPAA Transactions and Code SetsCurrently, there is no common standard for the transfer of information between healthcare providers and payers. As a result, providers had to meet many different payer requirements. For some providers who submit claims to hundreds of payers, programming their computer systems to meet these requirements has been a difficult and expensive process. HIPAA will change this practice by requiring payers to accept the following nine electronic transaction standard transaction for EDI:
The Accredited Standards Committee X12 (ASC X12) standards have been adopted for nearly all of these transactions. In particular, the standardized implementation guidelines developed by X12N will be adopted, starting with version 4010. These implementation guidelines can be found at www.wpc-edi.com/hipaa. They can be obtained for free, but registration is required. Pharmacy claims transactionsThe one exception to the adoption of X12 standards is for pharmacy claims, where the National Council for Prescription Drug Programs (NCPDP) standard will be adopted. Code Sets:Diagnoses and inpatient hospital services: International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM). The standard will likely migrate to ICD-10 once the new system is ready for adoption. Institutional services: ICD-9-CM Volume 3 and HCFA Common
Procedural Coding System (HCPCS) To review the regulations in their entirety, go to: http://www.gpoaccess.gov/cfr/index.html search for The Code of Federal Regulations Title 45, Section 160 through 164
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