Provider materials and tools

HIPAA mandates that all electronic transactions include only HIPAA compliant codes; therefore, Magellan requires the use of HIPAA compliant codes on all claims. If a claim is found to contain a non-compliant code, it will be rejected and returned to you for correction before processing.

To assist you in understanding the HIPAA compliant coding required we are providing the following guidelines.

Professional services (claims submitted primarily on CMS-1500)

Diagnosis: Use current version of ICD-9-CM codes (not DSM5) for diagnosis on claim submissions (Box 21) through September 30, 2015 and use ICD-10-CM codes as of October 1, 2015 (See the CMS ICD-10 website for additional information about this code set transition.)

Procedure Codes: Use current CPT® (HCPCS Level 1) codes to bill for professional services (Box 24d). CPT® codes are updated annually and become effective on January 1st of each year.

Place of Service: Use current Place of Service Codes. (Box 24b).

Facility/Program services (submitted primarily on UB-04)

Use the current HIPAA compliant coding recommendations from the Magellan universal services list (USL) (163K PDF) when billing for facility or program services:

  • Use ICD-9-CM codes (for diagnosis)
  • Revenue codes
  • Type of Bill Codes
  • CPT® codes for (professional services)
  • HCPCS Level II National Codes and Modifiers

Organizational providers that provide outpatient therapy services for commercial accounts must submit a license level modifier (85K PDF) for the rendering provider.

Where do I find the code sets?

CPT® codes are copyrighted by the AMA and must be obtained through that organization.

ICD-9-CM manuals may be ordered from the AMA by calling 800-621-8335, or from Channel Publishing at 800-248-2882. A CD-ROM of the complete listing can be ordered from the United States Government Printing Office at: US Government Printing Office, PO Box 371954, Pittsburgh, PA 15250-7594 or call the Ordering Office at 866-512-1800.

Note: All code sets are reviewed and subject to modification annually, so it is important to have the most current version of these codes for billing purposes. For more information on CPT code changes, please contact the AMA.

Facilities and programs

For facilities and program services, Magellan is providing the following HIPAA compliant code sets for your use:

Simplified billing codes (PDF 54K) - this document includes preferred billing codes for Magellan services submitted on UB-04 or CMS-1500 forms. This document is being provided as a guide to help expedite the billing and payment for some of the most common services.

Magellan universal service list (PDF 163K) - This document includes service definitions and a more comprehensive list of billing codes that apply to each service.

Please refer to the Magellan universal service list and simplified billing codes for recommended HCPCS Codes, HPCPS/CPT modifiers, Revenue Codes, Type of Bill and Place of Service codes for each service. HCPCS codes are only to be used if they appear on your Magellan reimbursement schedule or where directed by the Magellan Universal Services List.

Magellan will monitor the use of industry standard codes and provide feedback via Explanation of Payments (EOPs).

 

The Adobe Reader is required to view PDF files.