Medical Codes Overview
San Francisco Health Plan uses medical codes according to Medi-Cal billing guidelines in addition to Optum coding books application for claim activities. The following procedure medical codes must be used for a claim to be processed:
Professional charges – HIPAA compliant HCPCS Level 1 (CPT) & level 2
Inpatient hospital/facility/institutional charges – UB04 revenue codes
Outpatient hospital/facility charges – HCPCS Level 1 & 2 codes
HCPCS Level 3 codes until retired by DHCS.
Professional and institutional charges must be submitted as separate claims. If submitted on the same claim, one or the other type of charges will not be considered for payment. For example, if professional charges (CPT codes) are included on an institutional claim for an inpatient stay, then these charges will be automatically bundled under the per-diem payment. CPT codes, rather than HCPCS codes, should be used as first line coding when an appropriate code exists.
CPT-4 – Professional Services
HCPCS I – Physician Services
HCPCS II – Non-physician procedures and services
HCPCS III – California only
Revenue Codes – Inpatient facility services
Report ambulatory surgery, outpatient department visits, diagnostic testing and ancillary services using CPT, HCPCS Level II and III codes. EDI Claims submitted with invalid, incorrect or missing procedure medical codes will be denied.
- Surgery – 10000-69999
- Radiology – 70000-79999
- Pathology & Laboratory – 80000-89999
- Medicine – 90281-99199
- Evaluation & Management – 99201-99499
- Anesthesia – 00001-10000.
Conflicts with Other Common Core Data
EDI Claims are screened for conflicts with other patient and/or provider information. Reimbursement will not be made for claims where CPT procedure codes conflict with common core data, such as:
- Patient age/gender
- Place of service
- Provider specialty
Unlisted Services and Procedures
Claims for services submitted with unlisted CPT procedure codes (XXX99) require the following: Invoices of other pertinent information for DME, etc.; Medical records for surgical procedures; Documentation/Remarks or itemization of supplies; Authorization.
San Francisco Health Plan (SFHP) primarily serves Medi-Cal Beneficiaries under a contract with the State of California. SFHP generally follows policies and procedures of the Medi-Cal program. Unless otherwise noted, SFHP’s non-Medi-Cal lines of business also follow Medi-Cal policies and programs.