HIPAA Code Sets

The Federal HIPAA regulations issued by DHHS dictate that only approved code sets may be used in standard electronic transactions. The CMS site has official resources that define these standard code sets. The ICD-10 code sets are used to report medical diagnoses and inpatient procedures. The ICD-10 code sets were implemented effective October 1, 2015.

About ICD-10

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding System) consists of two parts:

     1. ICD-10-CM for diagnosis coding

     2. ICD-10-PCS for inpatient procedure coding

ICD-10-CM

is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS

is for use in U.S. inpatient hospital settings only. ICD-10­ PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

ICD-10 Quick Reference Guide for LTSS Providers

Please select the following link (ICD-10 Quick Reference Guide for LTSS Providers) to access Molina Healthcare’s quick reference guide for LTSS authorization requests and claims submissions.