Consolidated Health Informatics Initiative
Final Recommendation Information Sheet[1]

Domain Title and Team Lead

Billing/Financial:  Cynthia Wark, CMS


The Billing/Financial standards are used to implement electronic exchange of health related information needed to perform billing/administrative functions in the Federal health care enterprise.  It is assumed that the HIPAA transaction and code sets will serve as the basis for these standards.

Domain/Sub-domain In-Scope (Y/N)
Claim Submission for reimbursement Y
Health Care Claim Payment/Advice Y
Eligibility Determination Y
Prior Authorization and Referral Y
Enrollment/Disenrollment Y
Coordination of Benefits Y
Claims Status Inquiry Y
Appeals Y
Certificate of Medical Necessity Y
Claims Attachments N
Report of Injury N
Non-Claim Payment Electronic Funds Transfer N
Purchasing, i.e. Medical Supplies purchases N
Provider Identifiers N
Unique Patient Identifiers N
Employer Identifiers (Compliance date July ’04) Y
Advance Beneficiary Notification N
Electronic Signatures (being addressed by Text-Based Reports Workgroup) N

Alternatives Identified

The alternatives identified have been those code sets adopted under HIPAA:

  1. HCPCS and CPT 4, Healthcare Common Procedure Coding System and Current Procedural Terminology for physician services and other health services
  2. HCPCS for all other substances, equipment, supplies and other medical supplies
  3. ICD-9-CM, Vols 1&2 for diagnosis codes
  4. ICD-9-CM, Vol 3 for inpatient hospital procedures
  5. NDC, National Drug Codes for retail pharmacy claims
  6. CDT, Common Dental Terminology for dental services
  7. DRG, Diagnostic Related Groups
  8. Code sets internal to the approved X12 and NCPDP transaction implementation guides
  9. ABC codes

Additional codes sets identified:

  1. ICD-10-CM
  2. ICD-10-PCS


The HIPAA approved transactions and codes set, both those currently approved as well as future updates, are recommended for adoption.

HIPAA Medical Code Sets HIPAA non-Medical Code Sets
  • ICD-9-CM: Volumes 1 & 2 for diagnosis codes
  • ICD-9-CM: Volume 3 for inpatient hospital procedures
  • NDC: National Drug Codes for retail pharmacy claims
  • HCPCS and CPT-4 for physician services and other health services
  • HCPCS for all other substances, equipment, supplies, and other medical supplies
  • CDT for dental services
  • ABC Codes for registered users
  • Diagnostic Related Groups (DRGs)
ASC X12N 837
ASC X12N 820
ASC X12N 834
ASC X12N 835
ASC X12N 270/271
ASC X12N 278
ASC X12N 276/277
NCPDP Telecommunication Standards
  • Health plans (insurers) and health care providers who transmit any of the designated HIPAA transactions electronically within the Federal Government (Medicare, Veteran’s Administration, Department of Defense’s Military Health System and TRICARE Program, Indian Health Service, etc.) or external to it, are considered HIPAA covered entities and were required to be compliant with HIPAA transactions and code sets as of October 16, 2003.   Therefore, the HIPAA transactions and code sets are assumed to be the minimum standards for the CHI billing/administrative domain.
  • In addition to the HIPAA transaction and code set standards, the workgroup has identified ICD-10-CM as a standard to be considered.  The workgroup is aware that the NCVHS SSS has ICD-10-CM under study, therefore will follow this work as it evolves.
  • Claims attachments are considered out of scope due to the scheduled publication of the Attachment NPRM by HHS in 2004.  Work is underway between HL7 Attachments Special Interest Group and CHI staff to map and align CHI clinical standards with the proposed HL7 claims attachment standard.  Therefore, until this work has evolved further, the workgroup considers this out of scope and suggests the area be revisited in 12 months.
  • The X12 837 transaction could be used for certificates of medical necessity, however it is not a HIPAA approved transaction/code set. There are no federal agencies using an electronic standard for data or structure related to certificates of medical necessity, therefore no standard for this function is being recommended.

[1] Information Sheet designed specifically to facilitate communication between CHI and NCVHS Subcommittee on Standards and Security resulting from May 20, 2003 testimony.  CHI may seek assistance to help further define scope, alternatives to be considered and/or issues to be included in evaluation process.