HIPAA Code Sets
The Federal HIPAA regulations issued by DHHS dictate that only approved code sets may be used in standard
electronic transactions. The CMS site has official resources that define these standard code sets. Currently, the
healthcare industry is using a version of the code sets which is referred to as ICD-9. The ICD-9 code sets are used to
report medical diagnoses and inpatient procedures. The ICD-9 code sets will be replaced by ICD-10 code sets. CMS
had originally identified this date as October 1, 2013, but revisions have occurred which changed this date to
October 1, 2015.
About ICD-10
ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding
System) consists of two parts:
1. ICD-10-CM for diagnosis coding
2. ICD-10-PCS for inpatient procedure coding
ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead
of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.
ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10 PCS uses 7 alphanumeric digits instead of
the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific
and substantially different from ICD-9-CM procedure coding.
The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and
hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical
practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9
categories are full.
Who Needs to Transition
ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability
Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does
not affect CPT coding for outpatient procedures.
October 1, 2015 is the deadline for implementation of a new set of government-mandated healthcare diagnosis and
procedure codes called ICD-10. The new codes replace a much smaller, current set of codes available in ICD-9. The
new codes are more specific and will help the medical industry to better define clinical diagnoses, track medical
procedures, improve patient and member care, and better assess medical care needs. Molina has initiated a project to
ensure our readiness with the mandated deadline.
Molina is interested in coordinating with providers and facilities to help understand and mitigate potential impacts
through integrated testing as the industry upgrades to ICD-10. Specific questions and surveys can be directed
to Molina.ICD-10@MolinaHealthcare.com. We will continue to post updates regarding the ICD-10 upgrade as well
as information relevant to our provider community at this website.
Frequently Asked Questions
Please select the following link (Molina ICD Conversion FAQ) to review frequently asked questions related to
Molina Healthcare’s ICD-10 implementation.
ICD-10 Quick Reference Guide for LTSS Providers
Please select the following link (ICD-10 Quick Reference Guide for LTSS Providers) to access Molina Healthcare’s
quick reference guide for LTSS authorization requests and claims submissions.