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TRANSACTION STANDARDS, COMPLIANCE PLAN
& EXTENSION FORM

The Transactions and Code Sets Standards were published August 17, 2000 and currently the deadline for compliance is October 16, 2002, unless an extension is filed before October 16, 2002. Essentially, the Transactions and Code Sets Standards adopt standards for eight electronic transactions and requires standardized code sets to be used in those transactions. The Standards apply to all electronically based transactions, including those handled by telephone, email or Internet. All health plans, clearinghouses, healthcare providers and certain business associates are required to comply with the Transactions and Code Sets Standards.

TRANSACTIONS STANDARDS

• The transactions covered in the final transactions rule are as follows:

• Health claims and equivalent encounter information;

• Enrollment and disenrollment in a health plan;

• Eligibility for a health plan;

• Health care payment and remittance advice;
  

• Health plan premium payments;

• Health claim status;

• Referral certification and authorization; and

• Coordination of benefits.

HIPAA also authorizes the Secretary to develop additional standards as needed. Although HIPAA mandates standards for the first report of injury and for claims attachments, these standards have not yet been proposed. The government and private-sector standards development organizations ("SDOs") worked together to develop the health care transaction standards. The SDOs include Health Level 7, the National Council for Prescription Drug Programs ("NCPDP"), the National Uniform Claims Committee, the National Uniform Billing Committee and the American National Standards Institute, Accredited Standards Committee X12 ("ANSI X12"). SDOs continue to serve a vital role in HIPAA's implementation because they develop and maintain the models, data dictionaries, structure, syntax and implementation materials for electronic transaction standards.

CODE SETS

HIPAA's code sets rule requires the use of standard code sets, which are a set of codes used for encoding data elements such as medical terms, concepts or diagnoses. A code set includes both the codes and the code descriptors.

Whenever a covered entity conducts a transaction, it must use the appropriate medical and nonmedical code sets as stipulated in the code sets rule. Most health plans, clearinghouses and providers already are using the medical data code sets that are required. These code sets include the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM), Vol. 1 and Vol. 2; the Health Care Financing Administration Common Procedure Coding System ("HCPCS"); the Current Procedural Terminology (CPT-4); National Drug Codes ("NDC"); and the Code on Dental Procedures and Nomenclature ("CDT").

The following chart details the conditions for which the various code sets are applied.

Conditions	Required Code Sets
Diseases, injuries, impairments, other health-related problems, their manifestations, and causes of injury, disease or impairment.	ICD-9-CM
Procedures or other actions taken to prevent, diagnose, treat, or manage diseases, injuries and impairments.	ICD-9-CM
Drugs and biologics used to prevent, diagnose, treat, or manage diseases, injuries and impairments.	NDC
Devices used to prevent, diagnose, treat, or manage diseases, injuries and impairments.	HCPCS
Physician services, physical and occupational therapy, radiology, laboratory tests, and other health services used to treat, prevent, diagnose, or manage disease, injuries and impairments.	CPT-4 and HCPCS
Dental services used to treat, prevent, diagnose, or manage disease, injuries and impairments.	CDT

DHHS did not establish a common schedule for implementing new versions of all HIPAA medical data code sets, because some of the code sets are updated annually and some are updated more frequently. The organizations that maintain the medical data code sets will specify their own update schedules.

The full text of the Transactions and Code Sets Standards can be found at http://aspe.hhs.gov/admnsimp/index.htm.

DEADLINE FOR COMPLIANCE WITH THE TRANSACTIONS AND CODE SETS STANDARDS

All healthcare providers must be prepared to comply with the Transaction Standards by October 16, 2002, unless they file a compliance plan on or before October 15, 2002, which will extend the compliance deadline to October 16, 2003.

GUIDELINES FOR FILING FOR TRANSACTIONS AND CODE SETS EXTENSION

To take advantage of the October 16, 2002 deadline extension, healthcare providers must submit a compliance plan request on or before October 15, 2002. CMS has developed a model plan that simplifies the filing process. Healthcare providers may submit their own version of a compliance plan that provides equivalent information as CMS' model plan or use the CMS model plan to create their own. Plans be submitted online or via hard copy. If healthcare providers submit the plan electronically, CMS will provide an electronic confirmation of the plan.

Click here to view the CMS Model Plan, or go to http://www.cms.hhs.gov/hipaa to complete and file your plan.