Q: ICD-9-CM codes on outpatient claims

Q: Can ICD-9-CM procedure codes be reported on hospital outpatient claims? If I use HCPCS codes to report hospital outpatient services at the "required" service line level segment for a claim, may I use the ICD-9-CM procedure codes to report hospital outpatient services at the claim level "situational" segment?

A: No. ICD-9-CM procedure codes were named as the HIPAA standard code set for inpatient hospital procedures. The ICD-9-CM procedure codes were not named a HIPAA standard for procedures in other settings such as hospital outpatient services or other types of ambulatory services. Hospitals may capture the ICD-9-CM procedure codes for internally tracking or monitoring hospital outpatient services; but when conducting standard transactions, hospitals must use HCPCS codes to report outpatient services at the service line level and the claim level, if the situation applies. Even though an ICD-9-CM procedure code qualifier is available, in addition to a HCPCS code qualifier, at the "situational" claim level segment, the Transactions and Code Sets regulation states that ICD-9-CM procedure codes is the adopted standard code set for hospital inpatient services.

In order to continue operations and maintain cash flow, providers, as part of their contingency plan, could continue to report hospital outpatient services with ICD-9-CM procedure codes if required by the health plan. However, health plans must realize that reporting hospital outpatient services with ICD-9-CM procedures codes on standard claim transactions is not compliant, and that their good faith efforts to come into compliance must include the steps being taken to change this requirement.

This question and answer are taken from the Frequently Asked Questions section of the CMS Website.




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