Code Sets

Please use the following code sets when submitting paper or electronic claims.

• International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM). Available from the U.S. Government Printing Office by phone at (202) 512-1800 or by fax at (202) 512-2250.
• Current Procedural Terminology, 4th Edition (CPT-4). Available at www.ama-assn.org/ama/pub/category/3113.html.
• HCFA Common Procedure Coding System (HCPCS). Available at www.hcfa.gov/medicare/hcpcs.htm.
• National Drug Codes (NDC). Available at www.fda.gov/cder/ndc/index.htm.
• Code on Dental Procedures and Nomenclature, 2nd Edition. (CDT-2). Available from the American Dental Association by phone at 1-800-947-4746 or at www.ada.org.

If a procedure cannot be classified by a CPT or HCPCS code, please include the following information, as applicable, with the claim form:

• A full, detailed description of the service provided.
• A report, such as an operative report or a plan of treatment.
• Any information that would assist in determining the service rendered.

This information is also needed if a procedure is assigned an unlisted CPT/HCPCS code. For example, 84999 is an unlisted lab code that would require additional explanation.

Clinical Editing

At CareSource, we employ the latest in proven computer technology to process your claims accurately and efficiently. To this end, CareSource uses clinical editing software to help evaluate the accuracy of diagnosis and procedure codes on submitted claims.

CareSource’s clinical editing software finds any coding conflict or inconsistent information on claims. For example, a claim may contain a conflict between the patient’s age or sex and diagnosis, such as a pregnancy diagnosis for a male patient. Our software resolves these conflicts or indicates a need to seek additional information from the health care provider.

Please remember that CareSource’s clinical editing software helps evaluate the accuracy of the procedure code only, not the medical necessity of the procedure. We believe that clinical editing software helps ensure that your claims are processed consistently, accurately and efficiently.