Transactions and Code Sets

The final rule for Transactions and Code Sets, published in the Federal Register August 17, 2000, establishes standards for electronic transactions and external medical data code sets as illustrated in the following tables.

Transactions

Transaction Type Standard
Claim or Equivalent Encounter Information - Professional ASC X12N 837 - Health Care Claim: Professional, Version 4010, May 2000
Claim or Equivalent Encounter Information - Institutional ASC X12N 837 - Health Care Claim: Institutional, Version 4010, May 2000
Claim or Equivalent Encounter Information - Dental ASC X12N 837 - Health Care Claim: Dental, Version 4010, May 2000
Claim or Equivalent Encounter Information - Retail Pharmacy NCPDP Telecommunications Standard Format, Version 5.1 September 1999 NCPDP Batch Standard Format, Version 1.0 February 1, 1996
Remittance Advice ASC X12N 835 - Health Care Claim Payment/Advice, Version 4010, May 2000
Claim Status and Response ASC X12N 276/277 - Health Care Claim Status Request and Response, Version 4010, May 2000
Eligibility Inquiry and Response ASC X12N 270/271 - Health Care Eligibility Benefit Inquiry and Response, Version 4010, May 2000
Enrollment and Maintenance ASC X12N 834 - Benefit Enrollment and Maintenance, Version 4010, May 2000
Requests for Review and Response ASC X12N 278 - Health Care Services Review - Request for Review and Response, Version 4010, May 2000
Premium Payment for Insurance Products ASC X12N 820 - Payroll Deducted and Other Group Premium Payment for Insurance Products, Version 4010, May 2000

Code Sets

Medical Data Code Set Purpose
International Classification of Diseases, ICD-9-CM, Volumes 1 and 2 Diagnoses
International Classification of Diseases, ICD-9-CM, Volume 3 Procedures Procedures, Inpatient
National Drug Codes (NDC) Drugs and Biologics
Code on Dental Procedures and Nomenclature Dental Services
Health Care Financing Administration Common Procedure Coding System (HCPCS) and Current Procedural Terminology, Fourth Edition (CPT-4) Physician and Other Health Services
Health Care Financing Administration Common Procedure Coding System (HCPCS) All Other Substances, Supplies, Equipment, or Other Items Used in Health Care Services