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HIPAA Codes
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates national standards for administrative codes and medical codes. State Medicaid agencies are required to use standardized medical code sets for medical diagnoses and for medical and dental procedures. Key HIPAA Procedural Codes are listed here. Note that this is not to be considered a complete list.
Learn more about HIPAA and the code sets.
The American Academy of Family Physicians (AAFP) has an excellent online toolkit of HIPAA Resources which includes transactions and code set standards, information on privacy and security, and links to obtain additional information.
Well Child Codes
HIPAA
Procedural Code |
HIPAA Modifier (As of 01/01/04) |
Procedure Code Description | Diagnosis Code | Reimbursement |
| Preventive Visits | ||||
| 99381
(new patient) 99391 (established patient) |
EP | Preventive Visit: 0 - 11 months | V20.2 | |
| 99382
(new patient) 99392 (established patient) |
EP | Preventive Visit: 1 - 4 years | V20.2 | |
| 99383
(new patient) 99393 (established patient) |
EP | Preventive Visit: 5 - 11 years | V20.2 | |
| 99384
(new patient) 99394 (established patient) |
EP | Preventive Visit: 12 - 17 years | V20.2 | |
| 99385
(new patient) 99395 (established patient) |
EP | Preventive Visit: 18 - 20 years | V20.2 | |
| Abnormal Screenings or Referrals | ||||
| 99381
(new patient) 99391 (established patient) |
EP | Abnormal Screening/Referral: 0 - 11 months | All ICD-9 Diagnosis codes excluding V20-V20.2, V70.0 and V70.3-70.9, V72.0, V72.1, V03.81, V04.8, V03.82, V06.1, V06.5, V06.4, V06.8, V04.0, V05.4, V74.1, and V82.5 to note that this is an abnormal screen. | |
| 99382
(new patient) 99392 (established patient) |
EP | Abnormal Screening/Referral: 1 - 4 years | ||
| 99383
(new patient) 99393 (established patient) |
EP | Abnormal Screening/Referral: 5 - 11 years | ||
| 99384
(new patient) 99394 (established patient) |
EP | Abnormal Screening/Referral: 12 - 17 years | ||
| 99385
(new patient) 99395 (established patient) |
EP | Abnormal Screening/Referral: 18 - 20 years | ||
Select ICD-9 (International Classification of Diseases, 9th Revision) Diagnosis Codes Commonly Used
ICD-9 |
Description |
| V03 | Need for prophylactic vaccination and inoculation against bacterial diseases |
| V04 | Need for prophylactic vaccination and inoculation against certain viral diseases |
| V05 | Need for other prophylactic vaccination and inoculation against single diseases |
| V06 | Need for prophylactic vaccination and inoculation against combinations of diseases |
| V20 | Health supervision of infant or child |
| V70 | General medical examination |
| V72 | Special investigations and examinations |
| V74 | Special screening examination for bacterial and spirochetal diseases |
| V82 | Special screening for other conditions |
Interperiodic Vision Only and Hearing Only Procedure Codes
HIPAA
Procedural Code |
HIPAA
Modifier (As of 01/01/04) |
Procedure Code Description | Diagnosis Code | Reimbursement |
| Vision | ||||
| 99173 | EP | Interperiodic vision, normal | V72.0 | |
| 99173 | EP | Interperiodic vision, abnormal | The appropriate ICD-9-CM diagnosis code | |
| Hearing | ||||
| V5008 | EP | Interperiodic hearing, normal | V72.1 | |
| 92551 | EP | Interperiodic
hearing, normal screening both ears, pure tone, air only |
V72.1 | |
| 92552 | EP | Interperiodic
hearing, normal screening both ears, pure tone audiometry (threshold); air only |
V72.1 | |
| 92553 | EP | Interperiodic
hearing, normal screening both ears, pure tone audiometry (threshold); air and bone |
V72.1 | |
| 92555 | EP | Interperiodic
hearing, normal screening both ears, speech audiometry threshold |
V72.1 | |
| 92556 | EP | Interperiodic
hearing, normal screening both ears, speech audiometry threshold with speech recognition |
V72.1 | |
| V5008 | EP | Interperiodic hearing, abnormal | The appropriate ICD-9-CM diagnosis code | |
| 92551 | EP | Interperiodic
hearing, abnormal screening both ears, pure tone, air only |
||
| 92552 | EP | Interperiodic
hearing, abnormal screening both ears, pure tone audiometry (threshold); air only |
||
| 92553 | EP | Interperiodic
hearing, abnormal screening both ears, pure tone audiometry (threshold); air and bone |
||
| 92555 | EP | Interperiodic
hearing, abnormal screening both ears, speech audiometry threshold |
||
| 92556 | EP | Interperiodic
hearing, abnormal screening both ears, speech audiometry threshold with speech recognition |
||
Immunization, Tuberculin Skin Test, and Blood Lead Test Procedure Codes
HIPAA
Procedural Code |
HIPAA
Modifier (As of 01/01/04) |
Procedure Code Description | Diagnosis Code | Reimbursement |
| 90647 | EP | Hemophilus influenza, type B (HIB) | V03.81 | |
| 90655 | EP | Influenza (preservative free) | V04.8 | |
| 90657 | EP | Influenza ages 0 - 3 years years (split virus) | V04.8 | |
| 90658 | EP | Influenza ages 3 - 20 years (split virus) | V04.8 | |
| 90659 | EP | Influenza ages 12 - 20 years (whole virus) | V04.8 | |
| 90669 | EP | (prevnar) Pneumococcal Conjugate | V03.82 | |
| 90700 | EP | DTAP | V06.1 | |
| 90702 | EP | DT | V06.5 | |
| 90707 | EP | MMR | V06.4 | |
| 90713 | EP | IPV | V04.0 | |
| 90716 | EP | Varicella | V05.4 | |
| 90718 | EP | TD | V06.5 | |
| 90723 | EP | (DTAP, Hep B, and IPV) | V06.8 | |
| 90732 | EP | Pneumococcal Polysaccharide | V03.82 | |
| 90744 | EP | Hepatitis B | V05.3 | |
| 90748 | EP | Combination HEP B and HIB | V06.8 | |
| 86580 | EP | TB Skin Test | V74.1 | |
| 36415 | EP | Blood Lead Test | V82.5 |
