Understanding Valid and Excluded ICD Diagnosis Codes
Each year, CMS releases lists of valid and excluded ICD-10 diagnosis codes. These lists are derived from the codes used for Medicare medical claims but are specifically tailored for Section 111 NGHP Claim Input File submissions. The purpose is to ensure that the diagnosis codes used for reporting are relevant and appropriate for liability and workers’ compensation scenarios, while distinguishing them from no-fault accident or injury situations where certain codes may not apply.
Diagnosis codes relevant for Section 111 reporting are maintained on these lists from year to year. The lists are updated annually to include newly valid codes and to revise descriptions of existing ones, reflecting the evolving landscape of medical billing diagnosis codes. This annual update ensures that reporting entities are using the most current and accurate codes for their submissions.
Distinguishing Valid from Excluded Codes
It’s important to note that not all code types are included in the valid lists for Section 111 reporting. For instance, certain categories of codes are systematically excluded. ICD-9 codes starting with “V” and ICD-10 codes beginning with “Z”, which relate to factors influencing health status and contact with health services (often termed “Z codes”), are typically removed from the valid lists. This exclusion is because while “V” codes in ICD-9 and “Z” codes in ICD-10 serve a purpose in broader medical coding, they are generally deemed unsuitable for Section 111 claim reports. However, it’s worth noting that “V” codes may still be relevant in specific contexts, such as identifying the Alleged Cause of Injury, Incident, or Illness, and thus are not always on the excluded ICD-10 code list.
Furthermore, CMS identifies certain valid diagnosis codes that, despite being technically valid, do not provide sufficient detail regarding the cause and nature of the illness, incident, or injury for Section 111 Claim Input File submissions. These codes are consequently added to the excluded lists. This process ensures that only diagnosis codes that offer comprehensive and useful information for Section 111 reporting are considered valid for NGHP plan types, streamlining the billing diagnosis codes process and improving data quality.
For those involved in Section 111 reporting, regularly consulting the most recent valid and excluded diagnosis code lists is crucial. This practice ensures accuracy in reporting and adherence to CMS guidelines, particularly when dealing with billing diagnosis codes for liability insurance, no-fault insurance, and workers’ compensation claims.
