HIPAA edit - ICD-9 Procedure Codes

The new edits will check for the presence or absence of specific medical procedure codes reported at the claim level for inpatient or outpatient hospital services.

These edits are being added in order to comply with the final Health Insurance Portability and Accountability Act (HIPAA) rule, which named the ICD-9-CM Volume 3 Procedure Codes, (including The Official ICD-9-CM Guidelines for Coding and Reporting) as the HIPAA standard medical code set for inpatient hospital services, and the HCPCS/CPT codes as the HIPAA standard medical code set for physician services and other health care services (including outpatient hospital procedures).

With the implementation of these edits Humana will:

(1) No longer accept outpatient hospital claims with ICD-9-CM Vol 3 procedure codes in either or both the Procedure Information segment (BQ) or Other Procedure Information (BR). Humana will follow the HIPAA standard medical code set of HCPCS/CPT codes for outpatient services. Humana's rejection message will state, "ICD-9 valid only for hospital inpatient bill types."

(2) No longer accept an inpatient hospital claim with a HCPCS/CPT code in either or both the Procedure Information segment (BP) or Other Procedure Information (BO). Humana's rejection message will state, "ICD-9 must be used for hospital inpatient reporting."

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