Billing Code Sets

Billing codes and modifier systems identified below are valid codes for the specified workers’ compensation transactions, in addition to any code sets defined by the standards adopted in 0800-02-26- .04. (1) “CDT-4 Codes” – codes and nomenclature prescribed by the American Dental Association. (2) “CPT® Codes” – the procedural terminology and codes contained in the “Current Procedural Terminology,” as published by the American Medical Association and as adopted in the appropriate fee schedule effective on the date of service. See 0800-02-17. (3) “Diagnosis Related Group (MS-DRG)” – the inpatient classification scheme used by CMS for hospital inpatient reimbursement. The MS-DRG system classifies patients based on principal diagnosis, surgical procedure, age, presence of co-morbidities and complications, and other pertinent data that demonstrate similar resource consumption and length of stay patterns as defined by Medicare. (4) “HCPCS” – CMS’ Healthcare Common Procedure Coding System, a coding system which describes products, supplies, procedures, and health professional services and which includes the American Medical Association’s (AMA’s) Physician “Current Procedural Terminology, CPT®, codes, alphanumeric codes, and related modifiers. (5) “ICD-9-CM Codes” – diagnosis and procedure codes in the International Classification of Diseases, Ninth Revision, Clinical Modification published by the United States Department of Health and Human Services are adopted by reference. (6) “ICD-10-CM/PCS Codes” – diagnosis and procedure codes in the International Classification of Diseases, Tenth Edition, Clinical Modification/Procedure Coding System maintained and published by the United States Department of Health and Human Services are adopted by reference. (7) “NDC” – National Drug Codes of the United States Food and Drug Administration. (8) “Revenue Codes” – the 4-digit coding system developed and maintained by the National Uniform Billing Committee for billing inpatient and outpatient hospital services, home health services, and hospice services. (9) “National Uniform Billing Committee Codes” – code structure and instructions established for use by the National Uniform Billing Committee (NUBC), such as occurrence codes, condition codes, or prospective payment indicator codes. As of the date of publication of this model rule, these are known as UB04 codes. (10) “Narrative Medical Reports” required by 0800-02-17-.15 shall use the procedure codes WC101, WC102 and WC103 as specified therein. (eBill Companion Guide – Chapter 2.8)