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Coding Information

HIPAA mandates that all electronic transactions include only HIPAA compliant codes; therefore, Magellan requires the use of HIPAA compliant codes on all claims. Claims with non-compliant codes will be rejected and returned to you for correction before processing.

To assist you in understanding the HIPAA compliant coding required, we provide the following guidelines.

HIPAA Coding Changes, effective Jan. 1, 2024

The American Medical Association (AMA) issued changes to CPT® Evaluation and Management (E/M) time descriptions for office E/M codes (99202-99205, 99212-99215) and nursing facility codes (99306,99308). 

The Centers for Medicare and Medicaid Services (CMS) released new HCPCS codes for E/M visit complexity for ongoing care (+G2211), psychotherapy crisis services furnished in non-facility settings other than office (G0017, +G0018) and for social determinants of health risk (SDOH) assessments (G0136). Follow E/M coding guidelines for proper payment--see Magellan's helpful E/M coding guidelines tip sheet

Magellan is amending provider agreements to reflect these coding changes to commercial reimbursement schedules. (Note: There may be specific plans that exclude coverage of the new HCPCS codes.) 


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 professional services for commercial health plans 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.

Correct Coding Edits

Magellan aligns with national industry code-editing standards that include, but are not limited to:

  • American Medical Association (AMA) Current Procedural Terminology (CPT®)
  • National Correct Coding Initiative (NCCI)
  • Healthcare Common Procedure Coding System (HCPCS)
  • International Classification of Diseases, 10th Edition (ICD-10).

Thank you for your attention to accuracy in your claims submissions, to reduce errors and expedite payment processing.

Facilities and Programs

For facilities and program services, Magellan provides 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 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.
  • Opioid Use Disorder Treatment Codes (PDF) - This document includes billing instructions for OTP MAT codes and SUD bundled service codes.

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.


Telehealth Billing

After you complete your telehealth attestation, you can begin delivering care via telehealth for members for whom it is a covered benefit.

Telehealth payable services - commercial plans (PDF)

Telehealth payable services - Medicare plans (PDF)

Telehealth billing instructions (PDF)

Note: Coverage for codes is subject to the provisions and limitations of the subscriber’s benefit plan including authorization requirements. Nothing in these documents should be construed as altering subscriber’s benefits.