Electronic Transactions and Code Set Standards: Frequently Asked Questions

This information is provided as guidance only. Providers should always consult with their privacy and security officer(s) or an attorney when considering their privacy and security policies.

What is the Electronic Transaction Rule?
What does the Transaction Rule require?
Which electronic transactions are covered by this rule?
What is the compliance date for this Transaction Rule?
What are the Medical Data Code Set Standards?
What is the compliance date for the data code set standards?
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What is the Electronic Transaction Rule?

This rule, also called the Electronic Data Interchange, or EDI, specifies how certain electronic transactions are transferred from one computer to another. The goal is to standardize the format of health care data, which will increase the portability and accessibility of health care information and decrease administrative costs associated with the transmission of such data.

Health care providers are not required to conduct HIPAA transactions electronically, but, if they do so, they must comply with these standards. Medicare providers who employ more than 10 full-time equivalent employees (FTEs) are required to submit claims electronically and are therefore bound by the transaction and data code set standards.

What does the Transaction Rule require?

The Transaction Rule is highly technical and complex. It specifies that certain electronic transactions must be formatted and sent in a particular way. The original standards, released in 2000, were updated in January, 2009 [PDF]. Specifically, the revised standards require ASC X12 Technical Reports Type 3 (TR3), Version 005010 (called Version 5010). Any programs being used to submit covered transactions must be in this format to comply with the rule.

Which electronic transactions are covered by this rule?

The following transactions are covered by the EDI rule:

Health care claims or equivalent encounter information
Health care payment or remittance advice
Coordination of benefits
Eligibility for a health plan
Health care claims status
Enrollment and disenrollment in a health plan
Referral certification and authorization
Health plan premium payments

What is the compliance date for the Transaction Rule?

Covered entities must comply with the technical standards (Version 5010) by January 1, 2012. Health plans cannot require compliance before this date; however, earlier compliance is allowed if both parties agree.

What are the Medical Data Code Set Standards?

In the original HIPAA code set rules, covered entities were to use the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) for reporting diagnoses. In the final rule [PDF] modifications to the data set standards were made. Specifically, the new rules mandate the use of ICD-10-CM for reporting diagnoses. There are also changes to required codes for inpatient hospital procedure coding, which is not typically handled by SLPs and is not covered in any depth in these FAQs.