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Office of Mental Health

Frequently Asked Questions:
Electronic Data Interchange (EDI)

Q:Is there a corresponding ICD-9 coding list to the DSM-IV codes for billing of mental health diagnoses, i.e. depression, anxiety disorder, adjustment disorder? (December 2003)

A: OMH has issued two forms, OMH 213 and OMH 214 , which provide detailed crosswalks between DSM IV and ICD-9 mental health diagnoses. These forms can be ordered from OMH Printing & Design Services by mail, fax (518 473-2684) or e-mail. In a cover note, please indicate which form(s) you need, how many copies and where they should be shipped. The OMH Printing & Design Services are located at 44 Holland Avenue, Albany, NY 12229.

Q:I am trying to find a list of HIPAA compliant place of service codes. (November 2003)

A: The table of codes for place of service is located in the 837-Health Care Claim - Professional Implementation Guide at Loop 2400, SVC-105.

Q:If a health care provider transmits electronically only authorizations/ pre-certifications, but nothing else, are they covered under HIPAA? (October 2003)

A: HIPAA mandates the use of standard transactions if the answer to the following two questions is yes: Is the information being exchanged electronically between covered entities? Has a HIPAA standard been developed for the type of information being exchanged? In your example, both of these criteria have been met and the use of the 278 service authorization is required. The number of HIPAA standards a health care provider needs to use, whether it's one, some, or all, is not a factor in this decision.

Q:Should providers of psychiatric housing (e.g., supported housing and halfway houses) follow the EDItransaction standards defined in the 837 institutional companion guide or the 837 professional guide? (September 2003)

A: Providers of psychiatric housing that are covered entities under HIPAA and that intend to electronically transmit claims for medical services, must follow the EDItransaction standards described in the 837 Institutional NYSDOH Companion Guide (4010X096A1), when billing NYS Medicaid. If their trading partner is Medicare or a commercial health plan, then providers should contact the health plan directly to find out which transaction applies, the 837 institutional or 837 professional health care claim. If, however, a psychiatric residence is not a covered entity and the claims are for non- medical services, then the current format the provider uses to obtain reimbursement from Medicaid still applies. To determine if you are a covered entity, go to the Health and Human Services (HHS) 'Covered Entity Decision Tool', at Leaving OMH site

Q: In current practice by the mental health field, many clinicians use the DSM-IV in diagnosing mental disorders. Can these clinicians continue current practice and use the DSM-IV diagnostic criteria? (September 2003)

A: Yes. The Introduction to the DSM-IV indicates that the DSM-IV is "fully compatible" with the ICD-9-CM. The reason for this compatibility is that each diagnosis listed in the DSM-IV is "crosswalked" to the appropriate ICD-9-CM code. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV codes, descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.

Q: Has Medicaid published a set of transaction codes for mental health service? (August 2003)

A: Detailed information on HIPAA compliant Medicaid transactions and code sets, including mental health service codes, is posted on New York State's HIPAA Medicaid web site, at Leaving OMH site The 837 Institutional NYSDOH Companion Guide and 837 Institutional NYSDOH Supplementary Guide provide technical details for HIPAA implementation and instructions on how to program HIPAA compliant billing software.

Q: I would appreciate clarification on how to properly bill the Medicaid code sets for mental health effective 10/03. It is my understanding that NUBC established revenue codes, however, I do not have a clear understanding of how we will achieve the necessary distinctions to receive proper reimbursement from Medicaid (i.e. 4301 vs. 4302, etc). Could you please provide insight into this? (August 2003)

A: The New York State Medicaid program requires both a valid procedure code and the 4-digit MMIS rate code on their 837 I claim form. In other words, if you are a provider licensed by the NYS Office of Mental Health you must continue to use your MMIS rate codes for all your rate-based Medicaid claims, together with a valid procedure code. The rate code is entered into the Value Information HI Segment (Value Code 24) of the 837 I form. There is only one rate code per claim. When reporting procedures for inpatient services, the principal procedure code is entered into the Principal Procedure Information HI Segment. Inpatient procedures must be reported with ICD-9-CM procedure codes. Additional Inpatient services may be reported in the Other Procedure Information HI segment. To learn more about Medicaid code set and billing changes and tips on how to get ready for HIPAA compliant transactions with Medicaid, please visit OMH's public HIPAA web site and the Health Department's eMedNY HIPAA web site at HIPAA/index.html"> Leaving OMH site

Q: Are mental health providers required to convert their charting from DSM-IV diagnostic codes to ICD-9 codes or does the requirement to use ICD-9 as the standard code set relate only to billing for mental health services, or more specifically only to electronic billing for mental health services? (June 2003)

A: ICD-9-CM Diagnoses is one of 6 national medical code sets adopted under HIPAA (the others being ICD-9-CM Procedures, CPT-4, HCPCS, CDT and NDC) that are required for any electronic financial or administrative health care transaction involving the transmittal of PHI between covered entities. Electronic billing (837 claim form) is one of the health care transactions set forth in the HIPAA Standards for Electronic Transactions.

Q: What exactly is the law on electronic transfer of PHI? I notice there is a count down for compliance. (June 2003)

A: As of October 16th, 2003, HIPAA requires the use of standardized formats and code sets for the electronic transmittal of certain health care transactions between covered entities. These transactions can be broadly defined as the electronic exchange of protected health information (PHI) between health care providers (such as hospitals, physicians, dentists, and clinicians) and payers (such as Medicare, Medicaid, Blue Cross, Metropolitan, Aetna) to submit bills, receive payments, and inquire about patient eligibility, the status of a claim, premium payments, and authorizations. If the electronic transmittal of your PHI does not fall into one of the HIPAA transactions, you may continue to use current practices, formats and code sets as long as you comply with the HIPAA privacy regulations. If, however, the electronic transfer of PHI involves a HIPAA transaction, such as billing and reimbursement between covered entities, then the HIPAA transaction and code set standards must be used.

You can read the final rule on Electronic Transaction Standards on the US Department of Health and Human Services (DHHS) HIPAA web site, at Leaving OMH site . Other good sources of information on electronic transaction standards are the CMS HIPAA Information Series for Providers at Leaving OMH site and the NYS Medicaid HIPAA Information Center web site, at Leaving OMH site

Q: We have heard that the DSM IV-R will no longer be the standard of coding for either electronic billing to third party payers OR in individual charts. Although many payers already require use of ICD-9 (and we have a system that allows a computer crossover between the two coding systems), it is the belief among some staff here that the hand-written charts themselves must reflect ICD-9 codes to "match" the billing. Is the DSMIV-R dead or have we been given incorrect information? Use of another coding system will require re-training for our DSM-trained social workers. (June 2003)

A: Health care providers have always been required to use the ICD-9 code set for patient diagnoses when billing Medicaid or Medicare. That requirement has not changed under HIPAA. In an effort to increase compatibility between the two code sets, the DSM-IV work group joined forces with the developers of IDC-9, and as a result, the terms (diagnosis labels and definitions) and codes provided in DSM-IV are now largely compatible with those provided in ICD-9 CM and ICD-10 (to be released in 2004).

Q: I am a mental health provider, certified by OMH. I receive funding from OMH in the way of grants and reimbursement from Medicaid for my large Medicaid eligible population. If either OMH or the Office of Medicaid Management within the NYS Department of Health file for the one year extension for compliance with the EDIregulations, am I automatically covered? (April 2002)

A: No. According to the Administrative Simplification Compliance Act (P.L. 107-105) enacted in December 2001, and guidance published by HHS, each covered entity is responsible for submitting its own request for an extension. No entity will be automatically granted an extension just because another entity it conducts most or all of its business with files a request for, or obtains, one.

Q: How do I go about requesting the one year extension on the EDIregulations? (April 2002)

A: The Center for Medicare and Medicaid Services (CMS) has put together a HIPAA Model Compliance Extension Form, which can be used by covered entities to request a one-year extension to the October 16, 2002 compliance date for standard transactions and code sets. If you access CMS' HIPAA site, Leaving OMH site , you can obtain a copy of the 26 question form. It is our understanding an electronic submission option will soon be available as well.

The extension law requires covered entities to submit an extension compliance plan by October 15, 2002. If you send your plan electronically, it has to be submitted on that date. If you are using a paper submission, it must be postmarked on or before that date.

Q: Who is a "covered entity" under the EDIregulations? (March 2002)

A: You are covered under the EDIregulations if you are a health plan, a health care clearinghouse, or a health provider who conducts business using electronic transactions.

Q: I am a health care provider, but I don't do any electronic transactions now, everything I do is done by paper. Does HIPAA require me to use the standard formats in my paper transactions, or even worse, does it require me to do all of my transactions electronically? (March 2002)

A: Under HIPAA, health care providers are not required to do transactions electronically. However, if they do, they must use the standards. If you do not engage in any electronic transactions, you are not covered by HIPAA and are not bound to use the electronic data exchange standards. However, whether or not it is otherwise to your advantage or disadvantage to remain a paper based system is a determination you will need to make.