HCPCS Codes and Diagnosis Codes Description For EDI Claims Processing

HCPCS CodesHCPCS Codes (Healthcare Common Procedure Coding System Codes) is a national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to process Medicare and Medicaid (Medi-Cal) claims on a national basis. HCPCS Codes is a three-level coding system that incorporates Physicians’ Current Procedural Terminology (CPT-4), National and Local codes. The HCPCS coding format for Level I is five-digit numeric. The format for Level II and III is an alpha character followed by four numeric digits.

The full range of codes for each level is as follows:

  • Level I is 00100 thru 01999 and 10000 thru 99999
  • Level II is A0000 thru V9999

The existence of a specific Level II HCPCS codes for a particular item or service is not a guarantee that the item or service is covered by San Francisco Health Plan.

Diagnosis Codes

San Francisco Health Plan requires a valid diagnosis code with each claim. EDI Claims submitted with invalid, incorrect or missing diagnosis codes will be denied. Diagnoses and procedures for inpatient admission and outpatient services should be coded using the International Classification of Diseases (ICD-9/10-CM or ICD-9/10-PCS). For sick visits, use the appropriate diagnosis code(s) for which the patient presented. Please provide the most specific ICD-9/10 code, down to the sixth-character level if appropriate.

Use V codes, the supplementary classification of factors influencing health status in accordance with ICD-9-CM V-code reporting guidelines.

Use E codes, the supplementary classification of causes of injury and poisoning in accordance with ICD-9-CM E code reporting guidelines.

EDI Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not be made for electronic claims where Diagnosis procedure codes conflict with common core data, such as: Patient age/gender, CPT code, Place of service, Provider specialty.

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