Code sets and transactions are standardized codes used for data elements in healthcare. These codes can simplify the exchange of information and lead to more collaboration within the industry. Codes can be used to check eligibility, treatment authorization, and more across healthcare practices.
The adoption of HIPAA transactions and code sets rules
The healthcare industry has made strides toward adopting standardized formats based on established classification systems, such as the ICD-9-CM and ASC X12N. Many federal agencies and larger private organizations have already mandated these systems in their healthcare programs, including Medicare and Medicaid. The advanced stage of adoption facilitated the swift implementation of the HIPAA transactions and code sets rules, with the proposed rules published in May 1998 and the final rules finalized in August 2000.
The HIPAA transactions and code sets covered
The HIPAA transactions and code sets rules encompass a list of healthcare activities, including:
- Payment and remittance advice, and electronic funds transfer
- Healthcare claims status
- Health plan eligibility benefit inquiry and response
- Claim or equivalent encounter information
- Health plan enrollment and disenrollment
- Referral certification and authorization
- Health plan premium payments
- Coordination of benefits
- Medicaid pharmacy subrogation
Read also: HIPAA's Transaction and Code Sets Rule
Frequent updates to the code sets
While the list of HIPAA transactions has remained relatively stable, with the addition of Medicaid pharmacy subrogation in 2009, the standards for the code sets used in these transactions are updated frequently. For instance, the ICD-9-CM code sets were replaced by ICD-10-CM in October 2015, the Healthcare Common Procedure Coding System (HCPCS) code sets are updated quarterly, and the National Drug Code Directory is updated daily.
The HIPAA operating rules
In addition to the HIPAA transactions and code sets rules, the healthcare industry has also had to comply with the HIPAA operating rules since January 2014. These rules, mandated by the Patient Protection and Affordable Care Act, place additional requirements on health plans to provide quicker and more detailed responses to healthcare providers' inquiries about individuals' eligibility for benefits, claim statuses, fund transfers, and remittance advice.
Ensuring compliance with the rules
Compliance with the HIPAA transactions and code sets rules is enforced by the Centers for Medicare and Medicaid Services (CMS), a division of HHS. CMS has the authority to investigate complaints from covered entities when another covered entity is using incorrect transaction codes or HIPAA identifiers, or failing to comply with the HIPAA operating rules.
If a complaint is justified, CMS can impose corrective action plans or civil money penalties for compliance failures. Additionally, through the Office of Inspector General, CMS can exclude healthcare providers from federal healthcare programs if the non-compliance is attributable to fraud, theft, abuse, neglect, or unlawful activity.
Related: What does the Centers for Medicare and Medicaid Services (CMS) do?
Paubox’s HIPAA Compliant Email API
Paubox offers a HIPAA compliant Email API designed to streamline the sending of transactional emails while upholding strict data protection standards. This solution enables healthcare providers to send emails containing protected health information (PHI) seamlessly, maintaining HIPAA compliance without adding extra complexity.
Paubox’s API features customizable dynamic templates for personalized email content and webhooks for real-time updates on email delivery status. It integrates effortlessly into existing applications, supporting the automation of communications such as appointment reminders, lab results, and patient onboarding notifications. With TLS encryption ensuring secure email transmission and audit logging tools for compliance tracking, Paubox helps healthcare organizations enhance operational efficiency while adhering to stringent data protection regulations.
Read more: HIPAA compliant email API for developers
FAQs
Does HIPAA apply to transactions and code set rules?
HIPAA, or the Health Insurance Portability and Accountability Act, applies to a wide range of healthcare-related activities, including transactions and code sets. These rules mandate the use of standardized formats for various administrative processes, such as eligibility checks, claims processing, and remittance advice, and more.
Do I need consent for transactions and code set rules?
The HIPAA transactions and code sets rules do not specifically require patient consent for the exchange of information related to the covered transactions. However, healthcare organizations must still adhere to HIPAA's privacy and security regulations, which outline the requirements for the protection of patient information and the appropriate use and disclosure of protected health information (PHI).
What can I use for transactions and code set rules?
To ensure compliance with the HIPAA transactions and code sets rules, healthcare organizations must use the standardized formats and code sets specified by the regulations. These include the ICD-10-CM for diagnosis codes, the HCPCS for procedure codes, the National Drug Code Directory for pharmaceutical products, and the ASC X12N transaction standards for various administrative transactions, such as claims, eligibility inquiries, and remittance advice.
Learn more: HIPAA Compliant Email: The Definitive Guide
Farah Amod
