Navigating the complexities of medical billing and reporting requires a strong understanding of diagnosis codes, especially when it comes to Section 111 reporting. For Non-Group Health Plans (NGHPs), including liability insurance, no-fault insurance, and workers’ compensation, accurate reporting is crucial. This involves utilizing the correct ICD-10 diagnosis codes, as mandated for the latest fiscal year. Resources are available to help Responsible Reporting Entities (RREs) and their agents stay compliant with these requirements.
Decoding ICD-10 Diagnosis Codes for Section 111 Reporting
The Centers for Medicare & Medicaid Services (CMS) annually releases lists of valid and excluded ICD-10 diagnosis codes. These lists are pivotal for entities involved in Section 111 reporting. The foundation of these lists comes from the ICD-10 diagnosis codes that healthcare providers and suppliers are required to use when submitting claims to Medicare. However, for Section 111 reporting, the applicability of these codes is carefully considered. While some diagnosis codes are perfectly relevant for liability and workers’ compensation scenarios, others may not be suitable for no-fault accident or injury reporting. CMS undertakes an annual review of all ICD-10 codes to pinpoint those appropriate for Section 111 NGHP Claim Input File Detail Record submissions.
Once a diagnosis code is deemed relevant for Section 111 reporting, it generally remains on the valid lists in subsequent years. The lists are not static; they are updated annually to incorporate newly validated codes and to refine the descriptions of existing codes. This ensures the lists remain current and reflective of the latest medical coding standards and reporting needs.
Exclusions and Specific Code Types in ICD-10 Reporting
It’s important to note that not all types of ICD codes are included in the valid lists for Section 111 reporting. For instance, ICD-9 codes that begin with “V” and their ICD-10 counterparts, which start with “Z”, are typically removed from the valid lists. ICD-9 “V” codes and ICD-10 “Z” codes both relate to factors influencing health status and encounters with health services. Consequently, these “Z” codes are also excluded from Section 111 claim reports. Despite this general exclusion, “V” codes might be used in specific situations, such as when identifying the Alleged Cause of Injury, Incident, or Illness. This specific use case is why “V” codes are not found on the excluded ICD-10 code lists.
Furthermore, CMS has identified certain valid diagnosis codes that, despite their validity in other contexts, do not offer sufficient detail regarding the cause and nature of an illness, incident, or injury. These codes are considered incomplete or inadequate for the detailed requirements of Section 111 Claim Input File submissions. Therefore, these less informative diagnosis codes are added to the excluded lists and will not appear on the valid lists provided for NGHP plan types. Understanding these exclusions is just as vital as knowing the valid codes to ensure accurate and compliant Section 111 reporting.
