Coding Classification Standards

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities, including health plans, healthcare clearinghouses, and certain healthcare providers. It also set the standards for the classification systems covered entities must use. Under HIPAA, covered entities must use certain codes to identify specific diagnosis and clinical procedures on claims, encounter forms, and other electronic transactions.

HIPAA names the following code set standards:

• International Classification of Diseases, 9th revision, Clinical Modification ICD-9-CM Volumes 1 & 2 (diagnosis codes) is maintained by the National Center for Health Statistics (NCHS), Centers for Disease Control (CDC) within the Department of Health and Human Services (HHS).
• International Classification of Diseases, 9th revision, Clinical Modification ICD-9-CM Volume 3 (procedure codes) is maintained by CMS
• Current Procedure Terminology (CPT) (outpatient procedure codes) is maintained by the American Medical Association
• Health Care Common Procedure Coding System (HCPCS)—This code set, established by the Centers for Medicare and Medicaid Services (CMS), primarily represents items and supplies and non-physician services not covered by the American Medical Association CPT-4 codes. More information is available on the CMS Web site
• International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) is the new diagnosis coding system developed as a replacement for ICD-9-CM, Volume 1 & 2. International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS) is the new procedure coding system developed as a replacement for ICD-9-CM, volume 3. The compliance date for ICD-10-CM for diagnoses and ICD-10-PCS for inpatient hospital procedures is October 1, 2014. More information on ICD-10-CM/PCS
• National Drug Code (NDC)—The NDC is a code that identifies the vendor (manufacturer), product, and package size of all medications recognized by the FDA

HIPAA also names specific standards for electronic transactions. For example, submitting medical claims.

Learn more about how clinical classifications and clinical terminology systems work together to form the foundation of information content in the electronic health record (EHR).