Section 5—Transaction and Code Set Policies
This section contains policies and procedures related to the various regulations governing the use of electronic transactions and code sets. This section of policies is less operational and more simply state what sets of transactions and codes are in use by the organization. As transaction standards or code sets requirements change due to regulatory requirements, these policies must be updated.
5.1 Use of Standard Transactions
Policy
All of the following transactions, when conducted electronically, will be in compliance with the federal standards for electronic transactions:
l Claim submission
l Claim status request
l Remittance advice and electronic fund transfer
l Coordination of benefits determination
l Eligibility and enrollment determination
l Referral authorization
l Health plan enrollment
l Health plan premium payment
5.1.1 Transaction Standard for Claim Submission and Coordination of Benefits
ASC X12N 837—Health Care Claim: Institutional, Version 5010 (ASCX12N/005010X223) Effective 01/01/2012
ASC X12N 837—Health Care Claim: Professional, Version 5010 (ASCX12N/005010X222) Effective 01/01/2012
ASC X12N 837—Health Care Claim: Dental, Version 5010 (ASCX12N/005010X224) Effective
01/01/2012
NCPDP Telecommunication Standard Implementation Guide, version D, release 0 (version D.0) Effective 01/01/2012
NCPDP Batch Standard Implementation Guide, version 1, release 2 (version 1.2) Effective
01/01/2012
5.1.2 Transaction Standard for Claims Status Inquiries
ASC X12 276/277—Health Care Claim Status Request and Response, version 5010 (ASC X12N/005010X212) Effective 01/01/2012
5.1.3 Transaction Standard for Remittance Advice and Electronic Funds Transfer
ASC X12N 835—Health Care Claims Payment/Advice, Version 5010 (ASCX12N/005010X221) Effective 01/01/2012
NACHA Corporate Credit or Deposit Entry with Addenda Record (CCD+) Effective January 1,
2014
NCPDP Telecommunication Standard Implementation Guide, version D, release 0 (version D.0) Effective 01/01/2012
NCPDP Batch Standard Implementation Guide, version 1, release 2 (version 1.2) Effective
01/01/2012
5.1.4 Transaction Standard for Referral Authorization
ASC X12N 278—Health Care Services Review—Request for Review and Response, version
5010 (ASCX12N/005010X217) Effective 01/01/2012
5.1.5 Transaction Standard for Eligibility Transactions
ASC X12N 270/271—Health Care Eligibility Benefit Inquiry and Response, version 5010 (ASCX12N/005010X279) Effective 01/01/2012
NCPDP Telecommunication Standard Implementation Guide, version D, release 0 (version D.0) Effective 01/01/2012
NCPDP Batch Standard Implementation Guide, version 1, release 2 (version 1.2) Effective
01/01/2012
5.1.6 Transaction Standard for Health Plan Enrollment
ASC X12 834—Benefit Enrollment and Maintenance, version 5010 (ASCX12N/005010X220) Effective 01/01/2012
5.1.7 Transaction Standard for Premium Payment
ASC X12N 820—Payroll Deducted and Other Group Premium Payment for Insurance Products, version 5010 (ASCX12N/005010X218) Effective 01/01/2012
HIPAA Customizable Compliance Plan Section 5—Transaction and Code Set Policies
5.2 Testing and Certification of Compliance with Federal
Transaction Standards
Policy
Staff members responsible for selecting, installing, operating, and maintaining information systems used to conduct electronic transactions will certify, or obtain certification from vendors, that the systems are able to conduct transactions electronically that comply with the federal standards.
5.3 Trading Partner Agreements
Policy
All contracts or agreements with trading partners will include the provisions that comply with federal regulation for trading partner agreements. These provisions:
l Describe the duties and obligations of both parties to the agreement, including any responsibilities for safeguarding the security and privacy of the information that the two parties exchange
l Require electronic transactions to be conducted in compliance with the federal standards for electronic transactions
l Prohibit any addition or modification of the data elements to a standard transaction
l Prohibit any use of codes that are not specified in a federal standard transaction code set
l May specify processing instructions for completing transactions between a provider and a third-party payer such as specific codes that, if present, will result in the rejection of the transaction
5.4 Updating Code Sets and Practices
Policy
Staff members responsible for coding claims will use only codes contained in the federal transaction standard code sets. Staff will update code sets when new codes are issued.
5.4.1 Diagnosis Coding
Note: Alter these code set assignments based on the type of organization being coded for.
Diagnoses must be coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM diagnosis codes).
5.4.2 Physician Services Coding
Physician services and surgical procedures must be coded using Physician’s Current Procedural
Terminology (CPT®).
CPT is a registered trademark of the American Medical Association.
5.4.3 Dental Services Coding
Dental services must be coded using the American Dental Association’s Code on Dental
Procedures and Nomenclature (CDT®).
5.4.4 Other Health-related Services Coding
Most other health-related services must be coded using the Healthcare Common Procedure
Coding System (HCPCS Level II).
5.4.5 Drug Coding
Drugs must be coded using National Drug Codes (NDC). In some instances, drugs are coded using HCPCS Level II codes in the physician office setting for appropriate billing to third party payers.