The HIPAA Transactions and Code Set rules are meant to bring standardization in the electronic exchange of patient-identifiable health related information. On the basis of Electronic Data Interchange (EDI) standards, the transactions and code set rules permit information exchange from computer to computer without any human intervention. In 1996, Congress, with the aim of bringing and enhancing effectiveness and efficiency in the healthcare system, introduced national standards for the electronic exchange of healthcare transactions. EDI is applicable to nine most relevant types of administrative and financial health care transactions used by payers, physicians and other providers, including claims submission, claims status reporting, referral certification and authorization, and coordination of benefits. Complying to HIPAA Transactions and Code Sets Rule As per HIPAA requirement, the medical data code set has to be standardized eliminating all local and proprietary codes. Complying with the code set standards is not difficult as many of the adopted code sets are already in common use. Then also, even after submitting claims, all practices are expected to be affected by the HIPAA transactions and code set standards, as the payers, health plans, and insurance plans will be converted to using the standards in order to comply with HIPAA. Implementing HIPAA Transactions and Code Sets Rule Implementing transactions and code set rules is a major business process reengineering which involves complex and expensive undertakings. However, transactions and code set rules are the only part of the HIPAA regulations which promise less overhead and more savings of office expense. Also, the standards offer a rapid improvement in the quality of service provided. For effective outcome of the standards, all you need to do is controlling the data output from your practice management system and send claims electronically in the standard formats.Need help with HIPAA transactions and code sets rules? What can be better option than attending one of the ComplianceOnline webinars on HIPAA? The webinars are done by the HIPAA experts who are working in this field for last 20-30 years. Achieving HIPAA-Compliant Workforce Training - Available as CD Back
Learn more about Administrative Simplification standards for electronic transactions: It’s the Law Health care providers, health plans, clearinghouses, and other HIPAA-covered entities must comply with Administrative Simplification. The requirements apply to all providers who conduct electronic transactions, not just providers who accept Medicare or Medicaid. Save Time and Costs While Helping Patients Standard transactions, operating rules, code sets, and unique identifiers allow information to be shared electronically in consistent ways. With common standards for content and formats, information moves quickly as it is shared between providers and health plans in predictable ways. These standards have the potential to decrease health costs, time spent on paperwork, and administrative burden, giving providers more time for patient care. And quick communications with insurers can help inform patients upfront about coverage, benefits, and out-of-pocket costs. Electronic communications can offer:
Keep Up to Date! Sign up for Administrative Simplification Email Updates and follow us on Twitter Technological advancements in the 1980s and 1990s transformed medical billing and physician payments from manual to electronic processes. However, standardization was needed to maximize the value of automation. The HIPAA Administrative Simplification provisions ensure consistent electronic communication across the U.S. health care system by mandating use of standard transactions, code sets and identifiers. More recently, the creation of operating rules has further improved the efficiency of data exchange. HIPAA established a set of standardized transactions that health plans, clearinghouses and providers must use when conducting business electronically to ensure uniformity in the communication of administrative information among stakeholders. Though HIPAA does not require providers to process transactions electronically, any provider that does must comply with these standards. The current version of the standard transactions is Accredited Standards Committee X12 version 5010. For more on standard transactions, visit the AMA’s Electronic Transaction Toolkits for Administrative Simplification page. In 2010, the Affordable Care Act mandated operating rules for industry participants to follow when conducting standard electronic transactions. These are guidelines for the electronic exchange of information not covered by the electronic transaction standards or their implementation specifications. The AMA regularly advocates with the Council for Affordable Quality Healthcare’s (CAQH) Committee on Operating Rules for Information Exchange (CORE) to develop rules that protect physicians’ interests and lessen administrative burdens. For more on operating rules, visit the CAQH CORE website. Under HIPAA, the U.S. Department of Health and Human Services (HHS) adopted specific code sets for diagnoses and procedures to be used in all transactions. These include the Current Procedural Terminology (CPT®) codes for outpatient services/procedures, the Health Care Procedure Coding System (HCPCS) for ancillary services/procedures and the International Classification of Diseases, 10th Revision (ICD-10) for diagnosis and hospital inpatient procedures. HIPAA also required the development of standard identifiers for employers, health plans, providers and patients to be used in transactions. So far, HHS has only mandated identifiers for employers (the Employer Identification Number, or EIN) and providers (the National Provider Identifier, or NPI). For more on the NPI, visit the Centers for Medicare & Medicaid Services (CMS) website.
In addition to the HIPAA Privacy, Security, and Enforcement Rules, the HIPAA Administrative Simplification Rule also includes the following rules and standards: Transactions and Codes Set Standards Transactions are activities involving the transfer of health care information for specific purposes. Under HIPAA, if a health plan or health care provider engages in one of the identified transactions, they must comply with the standard for it, which includes using a standard code set to identify diagnoses and procedures. The Standards for Electronic Transactions and Code Sets, published August 17, 2000 and since modified, adopted standards for several transactions, including claims and encounter information, payment and remittance advice, and claims status Any health care provider that conducts a standard transaction also must comply with the Privacy Rule. More information on the Transactions and Code Set Standards. Identifier Standards for Employers and Providers HIPAA requires that employers have standard national numbers that identify them on standard transactions. The Employer Identification Number (EIN), issued by the Internal Revenue Service (IRS), was selected as the identifier for employers and was adopted effective July 30, 2002. More information on the Employer Identifier Standard. HIPAA requires that health care providers have standard national numbers that identify them on standard transactions. The National Provider Identifier (NPI) is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses use the NPIs in the administrative transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. More information on the National Provider Identifier Standard. Back to Top |
What is the main purpose for standardized transactions and code sets under HIPAA
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