HIPAA Electronic Codes For Clinical Social Workers In Private Practice

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HIPAA Electronic Codes For Clinical Social Workers In Private Practice

Mirean Coleman, MSW, LICSW, CT
Senior Policy Associate

October 16, 2003

Effective October 16, 2003 the HIPAA Electronic Standards and Code Sets have been implemented. Clinical social workers in private practice and other health providers who transmit and/or receive patient health information electronically are required to be in compliance. However, on September 23, 2003 the Centers for Medicare & Medicaid Services (CMS) announced a contingency plan to accept noncompliant electronic transactions after October 16, 2003. This plan will ensure continued processing of claims from clinical social workers and other providers, who will not be able to meet the deadline and otherwise would have their Medicare claims rejected. Other insurance companies such as BC/BS have also issued a contingency plan. It is currently unknown how long the contingency plans will remain in effect. It is important for clinical social workers to contact all third party payers with whom they have contractual relationships to determine whether or not they have also issued a contingency plan.

CODES

HIPAA requires uniform code sets when seeking reimbursement for diagnoses and procedures provided. Clinical social workers should use the following code sets:

Diagnosis Codes: International Classification of Diseases, 9^th Edition, Clinical Modification (ICD-9-CM) or its updated counterpart. These codes are published by the United States Department of Health and Human Services, and are available from the United States Printing Office as well as private publishers. Some large bookstores may also sell this code book.
Procedural Codes: Current Procedural Terminology, 4^th Edition (CPT-4) or its updated counterpart. These codes are described in the Current Procedural Terminology 2004, which is a publication developed by the American Medical Association (AMA) and is available from the AMA at www.ama-assn.org/ama/pub/category

Clinical social workers may also contact NASW Information Center regarding CPT codes relevant to clinical social workers.

Some third party payers are supplying their providers with the necessary codes for HIPAA compliancy. Clinical social workers should also contact their third party payers directly for information about this benefit.

SOFTWARE

When filing electronically, clinical social workers should only use HIPAA-compliant practice management software for billings services. Third party payers may supply clinical social workers with the proper HIPAA-compliant software. If not, the clinical social worker should only purchase computer software with a HIPAA compliant seal. The software should be able to

Use the standard HIPAA format when submitting a claim;
Collect all information needed to complete a claim;
Be able to receive, process, and automatically post information;
Be able to query third party payers about the status of a claim and receive query responses;
Check patient eligibility status electronically and process the response; and
Send and receive referrals and authorizations electronically.

RESOURCES

Additional information about HIPAA electronic transactions and code sets may be obtained from CMS at www.cms.hhs.gov/hipaa, or from the NASW Web site. Log on to www.socialworkers.org and click on HIPAA highlights.

Areas of Practice

http://www.socialworkers.org/practice/clinical/102103.asp

1/4/2013