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HIPAA: Code Conversions

The Health Insurance Portability and Accountability Act (HIPAA) mandates the standardization of internal (administrative) code sets and the use of standard service/procedure code sets for transactions. The Medi-Cal program is using a phased approach to convert its interim (local) codes to national values.

The links below provide additional information about Medi-Cal code conversions. Providers and submitters are encouraged to check this page periodically for new information.

General FAQs

Click to expand the sections below:

Audiology/EPSDT Audiology/Speech Therapy

The audiology/speech therapy code conversion provides the strategy for converting HCPCS Level III procedure codes to valid HCPCS Level II national procedure codes for audiology, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and speech therapy services. HIPAA-compliant HCPCS procedure codes are identified to reimburse providers for the claiming of audiology and speech therapy services.

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CHDP

The Child Health and Disability Prevention (CHDP) program code conversion transitions providers billing CHDP Medi-Cal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services using local codes to billing these services with HIPAA-compliant code sets. Transitioning from billing services with local codes on the Confidential Screening/Billing Report (PM 160) to billing national codes on the CMS-1500 or UB-04 claims, or electronic equivalents, is based on a date-of-service cutover.

Refer to the CHDP Provider Manual and Bulletins page for more information.

FAQs

Dialysis

The dialysis code conversion establishes HIPAA-compliant procedure codes for dialysis services by replacing the non-HIPAA-compliant Z-codes. The alternative solution includes utilization of revenue codes, CPT codes, HCPCS Level II codes and modifiers.

Additional information for this project will publish as details are determined.

ECMO/ECLS Services

The ECMO/ECLS Services code conversion provides the strategy for converting the local procedure code to national procedure codes. HIPAA-compliant procedure codes are identified to reimburse providers for the claiming of ECMO/ECLS services.

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EPSDT Services: Home Health

A forthcoming code conversion will establish a method to distinguish Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for Home Health services. This code conversion will replace non-HIPAA-compliant local codes with national HIPAA-compliant HCPCS procedure codes. National codes identified in combination with an EP modifier will allow for the distinction from adults and preserve the current rate allotted for children. Children's Home Health services covered by Medi-Cal under EPSDT regulations are uniquely identifiable for the purposes of preserving benefits and rates.

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EPSDT Services: Psychology, Mental and Behavioral Health

A forthcoming code conversion will establish a method to Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for psychology, mental and behavioral services. This code conversion will replace non-HIPAA-compliant local codes with national HIPAA-compliant HCPCS procedure codes. National codes identified in combination with an EP modifier will allow for the distinction from adults and preserve the current rate allotted for children. Children's psychology, mental and behavioral services covered by Medi-Cal under EPSDT regulations are uniquely identifiable for the purposes of preserving benefits and rates.

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EPSDT Services

This code conversion will replace non-HIPAA-compliant Level III local codes with national HIPAA-compliant HCPCS Level II procedure codes. National codes identified in combination with an EP modifier will allow for the distinction of services rendered to adults from services rendered to children and adolescents. Children covered by Medi-Cal under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit will be uniquely identifiable for the purposes of preserving benefits and rates.

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FQHC/RHC/IHS-MOA

Rural Health Clinics (RHCs) extend Medicare and Medi-Cal benefits and provide health care services in rural areas of California. Specifically trained primary care practitioners administer the health care services needed by the community when access to traditional physician care is difficult.

Federally Qualified Health Centers (FQHCs) were added as a Medi-Cal provider type in response to the Federal Omnibus Budget Reconciliation Act (OBRA) of 1989. FQHCs provide health care services in rural and urban areas of California.

California's Indian health care delivery system consists of a network of Indian health programs delivering primary care services throughout California. The network includes programs that participate in Medi-Cal as either an Indian Health Services – Memorandum of Agreement (IHS-MOA) provider, a tribal FQHC, or an urban Indian FQHC. To participate in the IHS-MOA the Tribal program must operate under the authority of the Public Law (PL) 93-638, 25 USC 450 et seq. The IHS-MOA provider type allows tribal health programs to receive a federally established all-inclusive rate for Medi-Cal covered services.

The FQHC/RHC/IHS-MOA, code conversion establishes HIPAA-compliant procedure code sets for FQHC/RHC/IHS-MOA services and replaces the non-HIPAA-compliant HCPCS Level III codes commonly referred to as local per-visit codes. Providers will be using a combination of revenue codes, revenue codes and CPT-4 or HCPCS codes, or revenue codes and CPT-4 or HCPCS codes with a modifier.

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Home Health

The home health code conversion provides the conversion strategy for local home health care service procedure codes to national procedure codes. HIPAA-compliant HCPCS procedure codes are identified to reimburse providers for the claiming of home health services.

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Hospice

The hospice care code conversion provides the strategy for converting local hospice service procedure codes to national procedure codes. HIPAA-compliant HCPCS procedure codes are identified to reimburse providers for the claiming of hospice services.

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LTC

The current set of two-digit local codes used for the claiming of LTC services is replaced with revenue and diagnosis codes. Providers must bill on a UB-04 claim.

Additional information for this project will publish as details are determined.

Maternal Care Services and CPSP

The maternal Comprehensive Perinatal Services Program (CPSP) code conversion provides the strategy for converting the CPSP local codes to national procedure codes. HIPAA-compliant HCPCS Level II codes have been identified to reimburse CPSP providers.

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Medical Services Other

The medical services other code conversion makes the necessary system modifications to ensure the medical services codes are in compliance with HIPAA. The combination establishes HIPAA-compliant procedure codes for medical services and deletes existing local codes.

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Medical Transportation

The medical transportation code conversion terminates the following items used for billing medical transportation services: local codes, the current set of 46 non-HIPAA compliant local codes, and one local modifier. The conversion also establishes HIPAA-compliant HCPCS codes and HCPCS modifiers, including HCPCS origin/destination modifiers developed by the Centers for Medicare and Medicaid Services (CMS) exclusively for medical transportation services.

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Miscellaneous Services

A code conversion for the following services updates codes and discontinues local procedure codes:

  • Psoriasis day care
  • Sign language interpreter
  • Lead screen/council and blood-draw services
  • Services provided in specific Special Care Centers (SCC) to California Children Service’s (CCS) recipients

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MSSP

The Multipurpose Senior Services Program (MSSP) code conversion brings MSSP services into federal compliance by matching nonstandard HCPCS Level III codes to a pre-existing HIPAA internal or external code set. The National Uniform Billing Committee (NUBC) maintains and publishes the external code-set list of revenue codes. Medi-Cal intends to utilize the NUBC list of revenue codes as they pertain to MSSP services, along with CPT and HCPCS Level II codes.

Additional information for this project will publish as details are determined.

NICU/PICU Services

The Neonatal and Pediatric Intensive Care Unit (NICU/PICU) code conversion establishes HIPAA-compliant procedure codes by terminating the use of HCPCS Level III local procedure codes. The update references valid CPT Category I national procedure codes for bill-intensive, care-unit services for both neonatal and pediatric services.

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Organ Procurement

The organ procurement code conversion provides the conversion strategy for local organ procurement procedure codes to national procedure codes. HIPAA-compliant HCPCS procedure codes are identified to reimburse non-contract hospitals for the claiming of organ procurement services. The HIPAA-compliant procedure codes used to reimburse providers for the acquisition and procurement of organs from living or cadaver donors in preparation for transplant procedures, and to delete existing local procedure codes.

Outpatient Services

The outpatient services code conversion establishes HIPAA-compliant procedure codes used to reimburse providers for hospital outpatient services such as the use of hospital facilities, hyperbaric oxygen therapy and hotel services. This code conversion also deletes existing local procedure codes and replaces non-HIPAA-compliant Z-codes. The alternative solution includes utilization of revenue codes, CPT and HCPCS Level II codes and modifiers.

Additional information for this project will publish as details are determined.

Physical and Occupational Therapy

The physical and occupational therapy code conversion replaces HCPCS Level III codes, commonly referred to as local codes, with HIPAA-compliant CPT Category I and HCPCS Level II national codes. HIPAA mandated these changes to the billing requirements for physical and occupational therapy services.

Additional information for this project will publish as details are determined.

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Psychological and Mental Health Services

The psychological and mental health services code conversion established the HIPAA-compliant procedure codes for psychological and mental health services by replacing the non-HIPAA-compliant local codes. HIPAA-compliant procedure codes are identified to reimburse providers for the claiming of psychological and mental health services.

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