Code Sets

Overview

HIPAA requires the use of standard codes on covered electronic transactions, such as health care claims, to represent medical services or equipment, drugs, place of service, adjudication decisions, and many other clinical and administrative data sets. Standard code sets, in conjunction with standard transactions, are expected to simplify the administrative burden associated with health care.

To comply with these HIPAA provisions, the Department of Health Care Services (DHCS) must convert over 7,000 non-HIPAA compliant medical billing codes, in addition to approximately 2,000 administrative codes, which are currently used in the administration of health care programs such as Medi-Cal, Denti-Cal, Child Health and Disability Prevention (CHDP) program, and Indian Health Services.  This conversion effort significantly impacts DHCS operations and that of our providers, health plans and other exchange partners.

To help minimize disruptions in cash flow and services to DHCS providers, beneficiaries and DHCS program areas, DHCS has elected to implement code changes in multiple phases over a period of time.  DHCS has categorized all non-HIPAA compliant medical code sets into service areas and/or program areas.  These code categories are designated as End-to-End (E2E) projects.  Each E2E project follows the HIPAA Transactions & Code Sets Project Life Cycle, which standardizes the approach towards compliance by establishing a common set of completion criteria, milestones and deliverables.  This approach combines the business and technical requirements necessary to become compliant with the HIPAA code sets provisions.

Providers will be given advanced notice of code changes through Medi-Cal bulletins and, in some cases, special mailers distributed by the DHCS Fiscal Intermediaries (EDS and Delta Dental). It is extremely important that providers monitor their Medi-Cal bulletins for HIPAA related changes.  

Status

DHCS has made significant progress towards compliance with the HIPAA code sets provisions, however, much work remains. The following table provides a listing of DHCS E2E code projects that are either completed or set for future implementation.  Specific implementation dates for projects in progress are not available at this time; however, for planning purposes, we feel it is helpful to understand which codes are to be worked on next.