Questions Submitted by the Public, by Date Posted to the Website. Code sets named in Implementation Guides


In the ASC X12N Implementation Guide, there could be code sets listed which are not named in the final rule. For example, the Professional 837 Implementation Guide lists HCPCS, NDC Codes, HIEC Product Service Codes, and Mutually Defined Codes of which only the first two code sets are named in the final rule. Am I in HIPAA compliance if I use any code set not included in the final rule but listed in the Implementation Guide?


The standards adopted in the Standards for Electronic Transactions Final Rule do not include the Home Infusion EDI Coalition Coding System (HIEC). In the final rule we acknowledged that the coding systems adopted as national standards may not address all business needs, however, health plans must conform to the requirements for code set use specified in the final rule. Therefore, the use of HIEC or other codes not adopted in the final rule is not compliant with HIPAA. As stated in the final rule, segments exist in standard transactions that allow for manual processing of services for which codes have not been adopted.

We will be requesting corrections to the Implementation Guides to remove all references to code sets that have not been adopted under HIPAA.