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Where do we get the correct code sets?
As a general rule, all HIPAA compliant transactions will have to
use codes that have been designated as national standards and listed
in the HIPAA rule. In summary they are:
- CPT codes for Physician Services published by the American Medical
Association. The book can be purchased online at www.ama-assn.org/ama/pub/category/3113.html.
- CDT codes for Dental Services, with code books information at
www.ada.org/prof/prac/manage/benefits/cdtguide.html.
- NDC codes for Drugs. The pharmacy code set books can be downloaded
free of charge from www.fda.gov/cder/ndc.
- Michigan Medicaid Pharmacy codes are available at www.michigan.fhsc.com.
Open the Provider folder, open the Pharmacy information folder,
open the drug information folder and the NDC extracts.
- ICD-9-CM Vol. 3, Codes for Inpatient Hospital until ICD-10-CM
is ready. Code book information can be obtained at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm.
- HCPCS code book from Center for Medicaid and Medicare Services
(CMS): cms.hhs.gov/medicare/HCPCS.
- National UB-92 Billing Manual is published by the Medical Hospital
Association. Their website address is www.nubc.org/become.html.
- The State specific Uniform Billing Manual is published by the
Michigan Health and Hospital Association. Their website address
is members.mha.org/mha/ub92/intro.htm.
- Information can also be obtained from the HIPAA Primer, an online
course offered by Michigan Virtual University at healthcare.mivu.org.
These are on-line courses and are available via the Internet 7
days a week, 24 hours a day.
Our System Support Staff who are evaluating
HIPAA Compliance guidelines relating to individual payers, request
verification regarding the State of Michigan requirements as they
pertain to the Service Authorization Exception Code.
Per this code notes, it is used only in claims where providers are
required by state law, (e.g. New York State Medicaid) to obtain
authorization for specific services but, for the reasons listed
in REF02, performed the service without obtaining the service authorization.
REF02 - Reference Identification: Allowable values for this element
are:
- Immediate/Urgent Care
- Services Rendered in a Retroactive Period
- Emergency Care
- Client as Temporary Medicaid
- Request from County for Second Opinion to Recipient can work
- Request for Override Pending
- Special Handling
Will Michigan Medicaid require providers
to use the Service Authorization Exception Code?
The Service Authorization Exception code (Loop 2300, Segment REF,
data element REF02) is situational and dependent on the laws and
therefore policies of the respective state Medicaid program. It
is a segment that may be reported in all three 837 claim/encounter
formats: professional, institutional and dental. MDCH does not currently
require the service authorization exception code on 837 professional,
dental or institutional claims. When an emergency indicator is needed
to explain the absence of an authorization number, it is provided
in other data elements. Since this may change in the future, please
be sure to check the latest companion documents.
Do you use HCPCS codes with revenue
codes?
Yes, as specified. All 837 Institutional claims must have revenue
codes. Some revenue codes require HCPCS codes.
Will taxonomy codes be required for
claims?
Medicaid will require taxonomy codes until the addenda is adopted,
at that point they will become situational.
Do you know what taxonomy code I should
tell people to use in their 837p transactions? The code should go
into loop 2000A/PRV3. Agency (251400000X)? Public Health or Welfare
(25140906X)? Other?
Loop 2000A, Segment PRV, Data Element PRV03 is required to report
the taxonomy code of the Rendering Provider if the Rendering Provider
is the same entity as the Billing Provider and/or the Pay-to Provider.
If the Rendering Provider is different than the Billing and/or Pay-to
Provider, the PRV segment is coded in Loop 2310B, Rendering Provider.
In both instances the taxonomy code should be that which best represents
the specialty of the provider delivering the service and identified
in the “Health Care Provider Taxonomy” code list available
on the Washington Publishing Company web site: www.wpc-edi.com.
When will National Drug Codes (NDC)
be released?
MDCH does not maintain or distribute NDC codes. The department of
Health and Human Services maintains and continually updates the
NDC codes for all drugs. A list of NDC’s for drugs covered
by MDCH can be found on the First Health web-site: www.michigan.fhsc.com.
Does the use of ICD-9CM diagnosis codes
comply with HIPAA requirements?
Yes. Until such time as ICD-10CM are available.
Is the billing provider address, Loop
2010AA, N3/N4, the address of the location where the service took
place or the address of the agency?
As directed in the v.4010 Implementation Guides, the expected value
for Billing Provider Address, Loop2010AA, Segments N3 and N4 is
the address corresponding to the Provider identified in Loop2010AA
- NM1Segment, Elements NM101 thru NM109. Further, this would be
true for all 837s’ Professional, Dental, and Institutional.
Where can I find carrier codes for
filing with other insurances?
On the MDCH website at www.michigan.gov/mdch.
On the left side of the page click on “Providers.” This
will give choices under “Providers.” Click on “Information
for Providers.” From the list in the middle of the page click
on “Third Party Liability.” This will link to a page that
has “Carrier ID Listing” with a choice of alpha by “carrier
name” or numeric by “OI.”
Nursing Facility providers are questioning whether or not a crosswalk
will be provided from the current proprietary electronic NF claim
format to the 837-I or EMCv5.
Several elements reported on the proprietary form cannot be captured
on the new formats. MDCH policy changes under the Nursing Facility
(NF) transition to national standard claim formats through the Uniform
Billing Project have eliminated the use of some elements currently
reported on the proprietary format, or transitioned the use of those
elements to an entirely different claim format. Providers should
review the revised Chapter IV of the Michigan Medicaid Nursing Facility
Manual, and the State Uniform Billing Manual to assess impact on
provider-specific systems and modify individual claims data reporting
systems accordingly. The authoritative crosswalk from the UB-92
(both paper and electronic) to the 837-I is found in Appendix F
of the 837-Institutional Implementation Guide, version 4010.
How long are CMH and MHSA Providers
to use the code crosswalk provided by MDCH?
These are to be used until you are notified of a change by MDCH.
This will assure that MDCH’s MMIS system is able to process
the transactions.
When do you expect the code crosswalk
to change again?
Some code changes were recently published by CMS and are under review
at MDCH. Likewise, the annual update of HCPCS codes has been received
and is being reviewed. As soon as possible, Version 5 of the crosswalk
will be distributed and will not be retroactive to October 1, 2002.
NOTE #1 - CMS will continue to change codes indefinitely. MDCH
will revise the code crosswalk as necessary, establishing an effective
date for each revision. If consistent with the effective date established
by CMS, MDCH will provide 90 days lead-time.
NOTE #2 - As you work with your providers, if you learn of additional
procedure codes that are needed, please forward them to MDCH for
consideration as additions to the code crosswalk.
Has DCH developed a crosswalk to determine
what national codes will replace the nonstandard Michigan local
procedure codes?
Since mid 2001, DCH has been notifying providers of crosswalks from
local procedure codes to national codes. Providers are notified
by Bulletins and/or Numbered Letters at least 30 days in advance
of any coding change. This is an ongoing process which will continue
until all local codes are crosswalked to national codes. As more
crosswalks are finalized, providers will be notified by Bulletin
or Letter and posted on the website. All local Michigan Medicaid
codes will be eliminated in time to be compliant with HIPAA. Providers
will use only national standard codes for any service provided on
or after October 16, 2003. Keep in mind however that even though
a service may be billed after October 16, 2003, a local code may
be continue to be required if the date of service is prior to HIPAA
implementation.
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