Well-Child Care Toolkit

Well-Child Care Toolkit


Understanding HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that mandates the use of national standards and code sets for health transactions, as well as standards for privacy and security of health information. HIPAA allows persons to qualify immediately for comparable health insurance coverage when they change their employment. Title II of HIPAA gives the U.S. Department of Health and Human Services (DHHS) the authority to:

  • Mandate the use of standards for the electronic exchange of health care data
  • Specify what medical and administrative code sets must be used within those standards
  • Require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors)
  • Specify the types of measures required to protect the security and privacy of personally identifiable health care information

Code Sets

HIPAA mandates national standards for administrative codes and medical codes. State Medicaid agencies are required to use standardized medical code sets for medical diagnoses and for medical and dental procedures. A number of medical code sets have been selected by DHHS for use in HIPAA transactions:

  • Current Procedural Terminology, Revision 4 (CPT-4) codes: A medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA) These codes are used for non-institutional and non-dental professional transactions.

  • Healthcare Common Procedural Coding System (HCPCS) codes: A medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes.
    -- HCPCS Level I contains numeric CPT codes maintained by the AMA.
    -- HCPCS Level II contains alphanumeric codes used to identify various items and services not included in the CPT code set.
    -- HCPCS Level III contains alphanumeric codes assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes" and must have "W", "X", "Y", or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA - ZY range used for locally assigned procedure modifiers.

  • International Classification of Diseases, 9th Edition - Clinical Modifications (ICD-9) codes: A medical code set maintained by the World Health Organization. A U.S. extension, maintained by the CDC, identifies morbidity factors or diagnoses and certain procedures.

  • Current Dental Terminology (CDT) codes: A medical code set, maintained and copyrighted by the American Dental Association.

Accessibility and Copyright
Copyright and Disclaimers See the Companion Pocket Guide Accessibility Information