HIPAA: HIPAA Transactions and Code Sets Medi-Cal Implementation Plan
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- Electronic Data Interchange (EDI) and Paper Impact
- Provider Training
- Health Care Claims (ASC X12N 837)
- Additional Modifier Fields (HCFA 1500 and UB-92 only)
- Admit Type on Outpatient Claims
- Type of Bill
- Billing Limit Exception on Paper Claims (Vision, LTC, HCFA 1500, UB-92)
- Place of Service for Subacute Facilities
- Billing of ICD-9-CM V3 for Inpatient Providers
- Current National Revenue and Ancillary Code Billing Instructions for Inpatient Services
- Inpatient Revenue Code 173
- Use of Revenue Code 790 for Inpatient Lithotripsy Room and Board
- Span Dates of Service for Inpatient Claims
- Obstetrical Billing on Inpatient Claims
- Baby Born Outside of the Hospital (Local HCPCS Code Z9800)
- Use of ICD-9-CM V3 Codes on Inpatient Obstetrics Claims
- Transplant Services on Inpatient Claims
- Inpatient Mental Health Adolescent Claims
- Administrative Code Sets
- Service/Procedure Code Sets
- Medicare/Medi-Cal Crossovers
- Pharmacy Compound Drug Claim Submission
- Remittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835)
- Enrollment Process
- Testing and Activation Procedures
- Technical Specifications/Companion Guides
- Frequently Asked Questions
Electronic Data Interchange (EDI) and Paper Impact
Medi-Cal identified significant changes for electronic and paper billing submission requirements in order to comply with HIPAA standards.
These changes include the code set values and billing requirements described in the June 2003 Medi-Cal Update (both Part 1 and Part 2
bulletins) and also posted on this Web site. This month’s Medi-Cal Update provides further billing instruction changes,
primarily in the respective Part 2 bulletins. These updates are easily identified within bulletins by a Medi-Cal HIPAA logo, as shown above.
Changes will continue to be communicated in Medi-Cal Updates, at Medi-Cal training venues and on the Medi-Cal Web site.
Medi-Cal’s phased implementation plan requires providers to continue following existing billing instructions until otherwise notified in future Medi-Cal Updates. Medi-Cal has scheduled the first implementation phase effective for dates of service on or after September 22, 2003. The following information provides more details about this phase of HIPAA implementation.
topProvider Training
Provider training sessions focused on HIPAA-related billing practice changes began in June and continue through the summer. Medi-Cal is
incorporating HIPAA training sessions into the existing provider training seminar circuit as well as providing separate stand-alone training
in various cities throughout the state. The training sessions offer multiple modules with a focus on HIPAA history, resources, provider
impact, implementation plans, specific paper billing instructions and policy changes. Please check the
Medi-Cal Education & Outreach Web page, Medi-Cal Updates and target mailings for specific venues, dates and times.
Health Care Claims (ASC X12N 837)
Policy and specific paper billing information for Inpatient Services, Outpatient Services, Long Term Care, Medical Services and Vision Care
providers is included in the applicable Part 2 bulletin. Additional policy, billing instructions and provider manual replacement pages will
be included in future Medi-Cal Updates.
Additional Modifier Fields (HCFA 1500 and UB-92 only)
For dates of service on or after September 22, 2003, Medi-Cal will accept up to four modifiers on the HCFA 1500 and UB-92 paper claim forms,
as well as the ASC X12N 837, version 4010A1 Institutional and Professional formats. Providers must bill as follows for these formats:
- Paper HCFA 1500: Providers bill all modifier values immediately following the procedure code in Box 24D without any spaces.
- Paper UB-92: Providers bill the first two modifier values immediately following the procedure code in FL (Field Locator) 44 without any spaces. If there are more than two modifiers, remaining modifiers are billed in FL 49 of the same service line without spaces.
- ASC X12N 837, Version 4010A1 Professional: SV101-3, SV101-4, SV101-5, SV101-6.
- ASC X12N 837, Version 4010A1 Institutional: SV202-3, SV202-4, SV202-5, SV202-6.
Additional modifiers cannot be billed on any of the following formats:
- CMC Propriety (all claim types)
- Vision Care paper claims (45-1)
- ASC X12N 837, version 3041
- Version 4 Flat File
Admit Type on Outpatient Claims
For dates of service on and after September 22, 2003, providers must bill the Admit Type (FL 19 on paper claim and CL101-837 for V4010A1
Institutional) of “1” (Emergency) when billing for Outpatient Emergency Services.
Type of Bill
For dates of service on or after September 22, 2003, Inpatient Services providers and providers billing on the UB-92 for Outpatient Services
must enter the appropriate Type of Bill on UB-92 paper claims. Providers should no longer include the Place of Service in FL 50. For
providers who submit using the ASC X12N 837, Version 4010A1 Institutional format, the Type of Bill is required. The Type of Bill values can
be obtained from the National Uniform Billing Committee (NUBC) UB-92 Billing Manual.
Billing Limit Exception on Paper Claims (Vision, LTC, HCFA 1500, UB-92)
The HIPAA-mandated national delay reason code that replaces Medi-Cal's billing limit exception code is two characters. On the above listed
paper formats, for claims with dates of service on or after September 22, 2003, Medi-Cal will only accept the national delay reason code as
outlined in the ASC X12N 837 version 4010A1 implementation guide. This data must be submitted in the following fields on the paper formats:
- Medical Services and Allied Health (HCFA 1500): Box 24J. This field is large enough to accommodate the two-character delay reason code.
- Inpatient and Outpatient Services (UB-92): FL 31. This field is large enough to accommodate the two-character delay reason code. The billing limit exception code was previously submitted in condition code fields 24-30.
- Long Term Care (25-1): Boxes 11, 30, 49, 68, 87 and 106. The two-character delay reason code may not fit in these boxes since the original box on the claim form was created as a single-character field. The Medi-Cal system will be modified to pick up the data overflow to the left of the field.
- Vision Care (45-1): Box 9. The two-character delay reason code may not fit in this field since the original box on this claim form was created as a single-character field. The Medi-Cal system will be modified to pick up the data overflow to the left or right of the field.
Please see the June Medi-Cal Update for more information on billing all other formats.
topPlace of Service for Subacute Facilities
On Medical Services claims, Medi-Cal currently uses local code values 91 (Subacute Care) and 96 (Pediatric Subacute Care) to differentiate
between recipients who reside in an adult or pediatric subacute facility. For dates of service on or after September 22, 2003, providers
must bill national Place of Service code 99 in Box 24B in conjunction with modifier “HA” to indicate Pediatric and “HB”
to indicate Adult. These modifiers must be submitted with every procedure code on the claim.
On outpatient claims, Medi-Cal currently uses local code values “F” (Adult Subacute Care) and “M” (Pediatric Subacute Care) to differentiate between recipients who reside in an adult or pediatric subacute facility. For dates of service on or after September 22, 2003, providers must bill national Facility Type “27” in FL 4 in conjunction with modifier “HA” to indicate Pediatric and “HB” to indicate Adult. These modifiers must be submitted with every procedure code on the claim.
topBilling of ICD-9-CM V3 for Inpatient Providers
For inpatient claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after September
22, 2003, Inpatient Services providers must bill surgical procedures with ICD-9-CM Volume 3 codes to indicate the appropriate surgical
procedure. All other providers must continue to use the appropriate HCPCS procedure codes.
Current National Revenue and Ancillary Code Billing Instructions for Inpatient Services
Medi-Cal currently uses many national revenue and ancillary codes for inpatient services. Only those codes identified in the correlation
tables published in the June Medi-Cal Update have changed. Reimbursement for these codes, however, remains the same. Below is a list
of codes with special billing instructions for inpatient services.
Inpatient Revenue Code 173
Revenue code 173 (Nursery, Newborn, Level III) is a revenue code new to Medi-Cal that will be available for use by hospital providers for
claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after September 22, 2003.
Contract hospitals may use this code subject to contract negotiations with the California Medical Assistance Commission (CMAC); non-contract hospitals may utilize this code when billing usual and customary charges.
Use of Revenue Code 790 for Inpatient Lithotripsy Room and Board
Revenue code 790 is currently used by Medi-Cal as an ancillary code. For claims with a “From Statement Covered Period Date” (or
the equivalent electronic field) on or after September 22, 2003, code 790 will be used as a room and board revenue code for lithotripsy
services.
Span Dates of Service for Inpatient Claims
Inpatient claims will be adjudicated based on the “Statement Covers Period” (or the equivalent electronic field) to determine
which code value to use. Claims with a “From Statement Covered Period Date” prior to September 22, 2003 must bill the
appropriate local or national values. Claims with a “From Statement Covered Period Date” on or after September 22, 2003 must
bill the appropriate national values. This rule applies regardless of the date of admission or the length of the inpatient stay. Inpatient
claims using revenue codes inappropriate for the date of service will be returned to providers via the Resubmission Turnaround Document
(RTD) process.
Obstetrical Billing on Inpatient Claims
Providers currently bill local accommodation codes 085 (nursery acute without associated delivery) and 095 (nursery acute with associated
delivery). For claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after September
22, 2003, providers must bill national revenue code 172 (nursery newborn, Level II) instead of code 085 or 095. To distinguish a claim with
a delivery versus one without a delivery, providers must bill the appropriate ICD-9-CM Volume 3 procedure code when there is a delivery.
See the ICD-9-CM Volume 3 correlation table for the
appropriate codes.
Baby Born Outside the Hospital (Local HCPCS Code Z9800)
For claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after September 22, 2003,
Medi-Cal providers should provide the following information to bill this service:
- Revenue Code 119, 129, 139 or 159 in FL 42
- Admit Type 4 (Newborn) in FL 19
- Admit Source 4 (Non-sterile environment) in FL 20
Use of ICD-9-CM V3 Codes on Inpatient Obstetrics Claims
For claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after September 22, 2003,
providers must bill Obstetrics services, including TAR-free days, with the appropriate ICD-9-CM Volume 3 procedure codes instead of CPT-4
delivery codes. See the ICD-9-CM Volume 3 correlation table
for the appropriate codes.
Transplant Services on Inpatient Claims
Transplant services currently are billed using local accommodation codes that identify the specific type of transplant. For claims with a
date in the “Statement Covers Period” (or the equivalent electronic field) on or after September 22, 2003, all transplant
services must be billed using national revenue code 201 in conjunction with the appropriate ICD-9-CM Volume 3 procedure code that uniquely
identifies the specific transplant. See the ICD-9-CM Volume 3 correlation table provided in this bulletin for the appropriate codes.
Inpatient Mental Health Adolescent Claims
Providers currently contracted to bill accommodation code 097 (psychiatric acute [adolescent and child]) must bill with revenue code 114,
124, 134 or 154 for claims with a date in the “Statement Covers Period” (or the equivalent electronic field) on or after
September 22, 2003. Providers billing revenue code 114, 124, 134 or 154 will continue to be reimbursed at their contracted rate for mental
health services provided to adolescent/child recipients.
Administrative Code Sets
Medi-Cal’s administrative code correlation tables (
condition codes, Place of Service codes,
delay reason codes,
patient status codes and
value codes) were printed in the June Medi-Cal Update
and are posted on this Web site. The conversion of interim (formerly referred to as local) codes to national administrative codes will be
implemented using the same update process as the current annual HCPCS update, in which code application is effective based on the date of
service. The code values are effective for dates of service on or after September 22, 2003, for all billing media and all Medi-Cal
(fee-for-service), waiver and public health program areas. There is no transition (grace) period.
Service/Procedure Code Sets
Medi-Cal’s service/procedure code correlation
table (for Inpatient revenue codes) and policy and billing code changes (for Chiropractic, Orthotics and Prosthetics, and
Immunizations and Vaccines) were included in the June Medi-Cal Update and are also now posted on this Web site. Correlation tables
will not be developed for Chiropractic, Orthotics and Prosthetics, and Immunizations and Vaccines code sets and associated modifiers
because one-to-one correlations of interim (local) to national codes are not applicable for these groups. These specific code values are
effective for dates of service on or after September 22, 2003, for all billing media and all Medi-Cal (fee-for-service) and public health
program areas. There is no transition (grace) period.
The conversion of the remaining interim (local) codes to national service/procedure codes will be implemented in phases and effective based on date of service. All other interim code values remain in effect and will be used for billing purposes until providers are instructed otherwise. These changes will be announced in a future Medi-Cal Update.
While most correlation tables were provided in the June 2003 Medi-Cal Update, the Inpatient ICD-9, Volume 3 Surgical Codes table was not yet available. The table is now finalized and included at the end of this bulletin. The codes are listed in Medi-Cal current code value order. [See table: Surgical Code Crosswalk – Inpatient.] The correlation table is separated by media type (paper, current proprietary and non-standard formats, and HIPAA standard format). The values are not to be used for billing purposes for dates of services prior to September 22, 2003. The correlation tables apply to both paper and electronic claims submission.
topMedicare/Medi-Cal Crossovers
The California Medicaid Management Information System (CA-MMIS) will be modified to capture the Patient Account Number in an effort to
comply with the HIPAA Transactions and Code Sets Final Rule regarding health plans, health care clearinghouses and health care providers
who submit claim transactions electronically.
For Part-A Medicare crossover claims submitted via Medicare intermediaries, Medi-Cal is modifying the Medical Record Number/Patient Account Number field on the Remittance Advice Detail (RAD) form and the Medical Record Number field on the Automated Remittance Data Services (ARDS) file. Currently, Medi-Cal records the Medical Record Number submitted to Medicare by the provider. With the implementation of the X12N 837 Institutional format, the Patient Account Number will be reported in the Medical Record Number/Patient Account Number field on the RAD and in the Medical Record Number field on the ARDS file.
For Part-B Medicare crossover claims submitted via Medicare carriers, Medi-Cal is modifying the Medical Record Number/Patient Account Number field on the RAD and the Medical Record Number field on the ARDS file. Currently, Medi-Cal does not report on the RAD the Patient Account Number submitted to Medicare by the provider. The ARDS file contains the Medicare Insurance Claim Number (ICN) in the Medical Record Number field. With the implementation of the X12N 837 Professional format, the Patient Account Number will be reported in the Medical Record Number/Patient Account Number field on the RAD and in the Medical Record Number field on the ARDS file.
topPharmacy Compound Drug Claim Submission
Policy and specific billing information regarding pharmacy claims is included in the Pharmacy Medi-Cal Update bulletin. Additional
policy, billing instructions and provider manual replacement pages will be included in a future Medi-Cal Update.
Remittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835)
As previously published, Medi-Cal will begin generating the ASC X12N 835 transaction beginning October 1, 2003 for claims adjudicated on or
after September 22, 2003. Providers who elect to receive an electronic Remittance Advice in the ASC X12N 835 standard format can download
the remittance advice from the Internet Bulletin Board System (IBBS) beginning October 1, 2003.
The ASC X12N 835 transaction enrollment process begins July 21, 2003. An ASC X12N 835 transaction receiver must be an authorized Computer Media Claims (CMC) submitter or have a valid Medi-Cal Point of Service (POS) Network/Internet Agreement on file. Authorized providers are required to complete and sign the new Electronic Health Care Claim Payment/Advice Receiver Agreement form (included in the June 2003 bulletin) before they can receive ASC X12N 835 transactions from Medi-Cal or designate a receiver for 835 transactions. This form is added to the end of the Remittance Advice Details (RAD): Electronic section of the Medi-Cal provider manual and on the the Medi-Cal Forms page of the Medi-Cal Web site. Completed agreement forms must be sent to the address provided on the form in order to be processed. Providers will be notified when their enrollment is completed or if there is a problem with their application.
topThe following steps detail Medi-Cal’s enrollment process:
For New Enrollment:
Download the receiver agreement form from the Medi-Cal Web site or make a copy of the form from the provider manual. Be sure the form and revision numbers (DHS 6246, 5/03) are present and legible.
- Complete all boxes on the form.
- Sign and date the form on the last page.
- Mail to the address provided on the last page of the form.
For Updates:
If the update requires an addition of a receiver:
- Check the “Change” box on Page 1 and the second box on Page 6.
- Complete the required boxes on Page 1.
- In the receiver information section on the second page, enter the requested information and indicate “Add.”
- Sign and date the form on the last page.
- Mail to the address provided on the last page of the form.
For Deletions:
If the update requires a deletion of a receiver:
- Check the “Change” box on Page 1 and the second box on Page 6.
- Complete the required boxes on Page 1.
- In the receiver information section on the second page, enter the requested information and indicate “Delete.”
- Sign and date the form on the last page.
- Mail to the address provided on the last page of the form.
For Both an Update and Deletion:
If the update requires both an addition and deletion of a receiver:
- Check both the “Change” and “Cancel” boxes on Page 1 and the second box on Page 6.
- Complete the required boxes on Page 1.
- In the receiver information section on the second page, enter the requested information and indicate the receiver to be added and the receiver to be deleted.
- Sign and date the form on the last page.
- Mail to the address provided on the last page of the form.
For Cancellations:
- Check the “Cancel” box on Page 1 and the third box on the last page.
- Complete the required boxes on Page 1.
- Sign and date the form on the last page.
- Mail to the address provided on the last page of the form.
Providers will receive an acknowledgement letter within two weeks from the time the Electronic Health Care Claim Payment/Advice Receiver Agreement form was submitted. If the agreement form cannot be processed, the receiver form will be returned to the provider with a letter explaining the error(s) made on the form. Provider testing is not required prior to receiving ASC X12 835 transactions on the Medi-Cal Web site. Providers can call the Provider Support Center at 1-800-541-5555 and select prompt option “4” to check the status of their receiver agreement form.
Note: When a provider enrolls to receive an 835 transaction, the provider can choose to discontinue receipt of the paper RAD.top
Testing and Activation Procedures
Testing and activation for X12N 837 transactions begins July 23, 2003. Computer Media Claims (CMC) and paper claims must meet the same
edit and audit requirements based on Medi-Cal billing policy. Participation as a CMC submitter is open to all Medi-Cal providers. The
acceptable media submission types are dial-up, tape or Internet. For specific information regarding requirements for each media submission
type, refer to the Medi-Cal CMC Billing and
Technical Manual. The proper formats are the X12N 837 Institutional and Professional Version 4010 A1.
A signed Medi-Cal Telecommunications Provider and Biller Application/Agreement is required from CMC submitters prior to testing and implementation of CMC billing. All providers and billing services must sign a new agreement form to be activated for the X12N 837 V4010A1. Providers submitting electronic claims through a billing service also must complete and sign the provider portion of the form. Billing services submitting electronic claims must complete the biller portion of the form. Each provider for whom the billing service submits claims must complete the provider portion of this form. Application/agreement forms from physicians and physician groups must contain the group provider number and the signature of an authorized physician within the group. Individual providers who bill with the group number do not need to submit separate provider application/agreement forms.
Once enrollment is complete, submitters must send a test file to the CMC Unit. Test submissions should contain a cross section of claim type data that can be expected in a production environment and consist of a minimum of 10 claims for each claim type to be billed. A maximum of 100 claims is allowed for testing. Submitters should use data from previously adjudicated claims, as claims contained on the test file will not be processed for payment. Any format problems discovered during the testing period must be corrected and a new test file submitted for review prior to the final approval. Questions should be directed to the CMC Help Desk at (916) 636-1100.
Submitters may test for multiple media using the same submitter number. Once approval is received for each medium, submitters may use the same submitter number for all media. Billing services already tested and approved are not required to retest for each provider as long as they use the same approved CMC submitter number, format, medium and claim types. A new application/agreement form is still required for all new providers.
X12N 837 health care claim transactions may be submitted through the CMC system for providers who bill Long Term Care, Inpatient Services, Outpatient Services, Medical Services, Vision Care and Allied Health claim types. The X12N 837 transaction record format is described in the appropriate companion guide on the Medi-Cal Web site. Click on “HIPAA Update” and then “Draft HIPAA ASC X12N and NCPDP Technical Specifications.” Data elements included in a submission are either required for X12N 837 standard transactions or Medi-Cal claims processing.
The test telephone number is (916) 638-8127. Submitters using the CMC TelePoint telecommunications system should perform a protocol test before submitting test data. Additional information is available in the telecommunications submission section in the Medi-Cal CMC Billing and Technical Manual.
Submitters are notified of format infractions by one of the following methods:
- Submitters with access to the Medi-Cal Web site must log in through the Transaction Services page to view their error reports and files submitted.
- Submitters without Internet access will receive a call from the CMC Help Desk each time an error is encountered. Submitters may call the CMC Help Desk at (916) 636-1100 for help in correcting submission errors.
Approximately two weeks after the tests are processed, submitters receive a CMC test approval or denial letter with the test results. The test results also include a review of field data formatting specifications. This review is not a requirement for CMC submission approval. It is meant to assist in preventing claim denial due to format specification errors.
Test claims with formatting errors are identified with the following statement: “The following examples of errors were encountered. If these errors are not corrected, your claims may be returned or denied.” The specific data field and error description will follow. For example:
“05INFO5” RECIPIENT ID MUST BE 9, 10, 14 OR 15 CHARACTERS FIELD CONTAINS <12345678> COUNT 3 CLAIM SEQUENCE=0002
This error message identifies the error code (05INFO5), data field (RECIPIENT ID) and correct format specification (9, 10, 14 or 15 CHARACTERS). It also identifies the actual field contents (12345678) and the sequential location (2) of the first claim found to contain the error, as well as the total count (3) of errors detected in the submission.
Note: Each specific error code, such as “05INFO5,” will be listed only once, regardless of the number of claims found to have this error.Test tapes should be labeled according to the instructions in the CMC tape submission section of the Medi-Cal CMC Billing and Technical Manual.
Mail CMC test tapes to:
EDS Corporation
CMC Unit
P.O. Box 15508
Sacramento, CA 95852-1508
Send CMC test tapes delivered by courier to:
EDS Corporation
CMC Unit
3215 Prospect Park Drive
Rancho Cordova, CA 95670-6017
EDS must approve each CMC provider/biller for electronic claim submission of the new X12N 837 format. For new submitters and providers, EDS will notify the Department of Health Care Services (DHS) upon completion of the testing process. DHS will then place the submitter in “Active” (production) status and will send the provider and/or billing service a letter authorizing CMC submission. The letter will include the name(s) of the providers/billers authorized to submit claims.
topTechnical Specifications/Companion Guides
The Medi-Cal ASC X12N 837 Institutional and Professional Companion guides are being revised in July and will be available on this Web site
at the end of the month. The current versions of the guides are available in "Draft HIPAA ASC X12N and NCPDP Compound Specifications" on
the HIPAA ASC X12N and NCPDP Technical Specifications page.
Frequently Asked Questions
Medi-Cal developed a HIPAA Frequently Asked Questions section of
this Web site. Providers are encouraged to check regularly for updates. For more information about HIPAA and Medi-Cal’s
implementation plan, call the Provider Support Center at 1-800-541-5555 and select prompt option “4.”
top
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