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HIPAA Transaction & Code Sets Rule

Per HIPAA regulations, a Code Set is any set of codes used for encoding data elements, such as medical terms, medical concepts, medical diagnosis codes, and medical procedure codes. Code sets for medical data are required for administrative transactions under HIPAA for diagnoses, procedures, and drugs.

Medical data code sets used in the health care industry under HIPAA include coding systems for health-related problems and their manifestations; causes of injury, disease or impairment; actions taken to prevent, diagnose, treat, or manage diseases, injuries, and impairments; and any substances, equipment, supplies, or other items used to perform these actions.

Specifically, the following code sets are used in HIPAA transactions:

ICD-10-CM codes - International Classification of Diseases - Clinical Modification (Diagnoses)
ICD-10-PCS codes - Procedural Classification System (In-patient Procedures)
HCPCS codes - Healthcare Common Procedure Coding System
CPT-4 codes - Current Procedural Terminology
CDT codes - Code on Dental Procedures and Nomenclature
NDC codes - National Drug Codes

Note: ICD-11 goes into effect Jan 1, 2022.


HIPAA 5010 Rule

The Secretary of the Department of Health and Human Services (HHS) has adopted Accredited Standards Committee X12 Version 5010 as the next HIPAA standard used to regulate the electronic transmission of healh-care transactions. The prior standard for HIPAA transactions was Version 4010-A1.

Covered entities, such as health plans, health care clearinghouses, and health care providers, are required to conform to HIPAA 5010 standards. The compliance deadline for HIPAA 5010 was January 1, 2012.