HIPAA mandates that all electronic transactions include only HIPAA compliant codes; therefore, Magellan requires the use of HIPAA compliant codes on all claims. If a claim is found to contain a non-compliant code, it will be rejected and returned to you for correction before processing.
To assist you in understanding the HIPAA compliant coding required we are providing the following guidelines.
Professional Services (claims submitted primarily on CMS-1500)
Diagnosis: Use current version of ICD-10 codes (not DSM-5) for diagnosis on claim submissions (Box 21).
Procedure Codes: Use current CPT® (HCPCS Level 1) codes to bill for professional services (Box 24d). CPT® codes are updated annually and become effective on January 1st of each year.
Place of Service: Use current Place of Service Codes (Box 24b).
Facility/Program Services (submitted primarily on UB-04)
Use the current HIPAA compliant coding recommendations from the Magellan Universal Services List (USL) (PDF) when billing for facility or program services:
- Use ICD-10-CM codes (for diagnosis)
- Revenue codes
- Type of Bill Codes
- CPT® codes (professional services)
- HCPCS Level II National Codes and Modifiers
Organizational providers that provide outpatient therapy services for commercial accounts must submit a license level modifier (PDF) for the rendering provider.
Where Do I Find the Code Sets?
CPT® codes are copyrighted by the AMA and must be obtained through that organization.
You may order ICD-10-CM manuals from the AMA by calling 1-800-621-8335, or from Channel Publishing at 1-800-248-2882. Order a CD-ROM of the complete listing from the United States Government Printing Office at: US Government Printing Office, PO Box 371954, Pittsburgh, PA 15250-7594 or call the Ordering Office at 1-866-512-1800.
Note: All code sets are reviewed and subject to modification annually, so it is important to have the most current version of these codes for billing purposes. For more information on CPT code changes, please contact the AMA.
Facilities and Programs
For facilities and program services, Magellan is providing the following HIPAA compliant code sets for your use:
Simplified Billing Codes (PDF) - this document includes preferred billing codes for Magellan services submitted on UB-04 or CMS-1500 forms. This document is being provided as a guide to help expedite the billing and payment for some of the most common services.
Magellan Universal Services List (PDF) - This document includes service definitions and a more comprehensive list of billing codes that apply to each service.
Please refer to the Magellan Universal Services List (PDF) and Simplified Billing Codes (PDF) for recommended HCPCS Codes, HPCPS/CPT modifiers, Revenue Codes, Type of Bill and Place of Service codes for each service. HCPCS codes are only to be used if they appear on your Magellan reimbursement schedule or where directed by the Magellan Universal Services List.