Frequently Asked Questions About Code Set Standards Adopted Under HIPAA

What is a code set?

Under HIPAA, a "code set" is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes. Medical data code sets used in the health care industry include coding systems for diseases, impairments, other health related problems, and their manifestations; causes of injury, disease, impairment, or other health-related problems; actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments; and any substances, equipment, supplies, or other items used to perform these actions. Code sets for medical data are required for data elements in the administrative and financial health care transaction standards adopted under HIPAA for diagnoses, procedures, and drugs.

What code sets have been adopted as HIPAA standards?

The Secretary has adopted the following code sets as the standard medical data code sets:

International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9-CM), Volumes 1 and 2 (including The Official ICD-9-CM Guidelines for Coding and Reporting), as updated and distributed by HHS, for the following conditions:

1. Diseases.
2. Injuries.
3. Impairments.
4. Other health related problems and their manifestations.
5. Causes of injury, disease, impairment, or other health-related problems.

International Classification of Diseases, 9th Edition, Clinical Modification, (ICD-9-CM), Volume 3 Procedures (including The Official ICD-9-CM Guidelines for Coding and Reporting), as updated and distributed by HHS, for the following procedures or other actions taken for diseases, injuries, and impairments on hospital inpatients reported by hospitals:

1. Prevention.
2. Diagnosis.
3. Treatment.
4. Management.

National Drug Codes (NDC), as updated and distributed by HHS, in collaboration with drug manufacturers, for the following: [Note that Secretary Thompson has indicated in a letter to the NCVHS that HHS will publish an NPRM in the near future proposing to retract the adoption of NDC for all transactions save those for retail pharmacies.]

1. Drugs.
2. Biologics.

Code on Dental Procedures and Nomenclature, as updated and distributed by the American Dental Association, for dental services.

The combination of Centers for Medicare & Medicaid Services (formerly known as Health Care Financing Administration) Common Procedure Coding System (HCPCS), as updated and distributed by HHS; and Current Procedural Terminology, Fourth Edition (CPT-4), as updated and distributed by the American Medical Association, for physician services and other health related services. These services include, but are not limited to, the following:

1. Physician services.
2. Physical and occupational therapy services.
3. Radiological procedures.
4. Clinical laboratory tests.
5. Other medical diagnostic procedures.
6. Hearing and vision services.
7. Transportation services including ambulance.

The Centers for Medicare & Medicaid Services (formerly known as Health Care Financing Administration) Common Procedure Coding System (HCPCS), as updated and distributed by CMS, HHS, for all other substances, equipment, supplies, or other items used in health care services. These items include, but are not limited to, the following:

1. Medical supplies.
2. Orthotic and prosthetic devices.
3. Durable medical equipment.

Can HCPCS Level 3 codes established on a local basis still be used?

No. All local codes will be eliminated. Users that need codes must apply to the appropriate organizations (e.g. CMS for HCPCS codes, the AMA for CPT-4 codes) for national codes.

Where can I get more information about the code sets?

ICD-9-CM: Official version is available on CD-ROM from the Government Printing Office (GPO) at 202-512-1800 or FAX: 202-512-2250. The CD-ROM contains the ICD-9-CM classification and coding guidelines. Versions of ICD-9-CM are also available from several private sector vendors.

CPT-4: Official version is available from the American Medical Association. Versions are also available from several private sector vendors.

HCPCS: Information about HCPCS is available from the CMS by searching their web site at http://cms.hhs.gov.

Code on Dental Procedures and Nomenclature: Official version is available from the American Dental Association at 800-947-4746.

NDC: Official versions of the files are available on the Internet at http://www.fda.gov/cder/ndc/index.htm. NDC codes are also published in the Physicians’ Desk Reference under the individual drug product listings and "How supplied." The supplements are available quarterly on diskette from the National Technical Information Service at 703-487-6430.