Transactions and Code Sets Regulations

Standards for Electronic Transactions-New Versions, New Standard and New Code Set - Final Rules

On January 16, 2009, HHS published two final rules to adopt updated HIPAA standards; these rules are available at the Federal Register. 

In one rule, HHS is adopting X12 Version 5010 and NCPDP Version D.0 for HIPAA transactions. In this rule, HHS also adopts a new standard for Medicaid subrogation for pharmacy claims, known as NCPDP Version 3.0.  For Version 5010 and Version D.0, the compliance date for all covered entities is January 1, 2012. This gives the industry enough time to test the standards internally, to ensure that systems have been appropriately updated, and then to test between trading partners before the compliance date. The compliance date for the Medicaid subrogation standard is also January 1, 2012, except for small health plans, which will have until January 1, 2013 to come into compliance.

In a separate final rule, HHS modifies the standard medical data code sets for coding diagnoses and inpatient hospital procedures by concurrently adopting the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and the International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) for inpatient hospital procedure coding. These new codes replace the current International Classification , 9th Revision, Clinical Modification, Volumes 1 and 2 and the International Classification , 9th Revision, Clinical Modification, Volume 3 for diagnosis and procedure codes respectively. The implementation date for ICD-10-CM and ICD-10-PCS is October 1, 2013 for all covered entities. 

Version 5010 accommodates the ICD-10 code sets, and has an earlier compliance date than ICD-10 in order to ensure adequate testing time for the industry. These two rules apply to all HIPAA covered entities, including health plans, health care clearinghouses, and certain health care providers.

To view both final rules, see the links in the Related Links Outside CMS section below.

To view the Fact Sheets for both rules, see the link in the Related Links Inside CMS.

To view the proposed rules, which were published on August 22, 2008, see the link in the Downloads section below.

Impact Analysis Reports for the Proposed and Final Rule on HIPAA Modifications

The document titled:  Adjusted Costs and Benefits for Version 5010, D.0 and 3.0 includes the industry specific tables showing net present values based on the costs and benefits estimated to impact health plans, health care clearinghouses and covered health care providers when implementing Version 5010, D.0 and 3.0 (CMS-0009-F).  To view, see the link in the Downloads section below.

Version 5010 Regulatory Impact Analysis-Supplement

This document summarizes the assumptions described in the impact analysis for CMS-009-F, and offers additional narrative for the calculations in each category.  It only covers the cost benefit analysis for Version 5010, and does not address NCPDP Version D.0 or 3.0.  To view this document, see the link in the Downloads section below.

Modifications Rule to Electronic Data Transaction Standards and Code Sets published February 20, 2003

To view, see the link in the Downloads section below.

Standards For Electronic Transactions-Final Rule published August 17, 2000

To view, see the link in the Downloads section below.

Standards For Electronic Transactions-Corrections

Technical corrections to the final rule were published in the Federal Register on November 24, 2000. To view, see the link in the Downloads section below.

Designated Standards Maintenance Organizations (DSMO)

The Designated Standards Maintenance Organizations were announced in the Federal Register on August 17, 2000. To view, see the link in the Downloads section below.

Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claims Status Transactions

To view the rule, see the link in the Related Links Outside CMS section below.