Diagnosis Codes are critical for accurate medical claims processing, especially within the framework of Section 111 reporting for Non-Group Health Plans (NGHPs). For entities responsible for liability insurance, no-fault insurance, and workers’ compensation claims, understanding the valid and excluded diagnosis codes is essential for compliance and proper reporting.
Navigating ICD-9 and ICD-10 for Compliance
Each fiscal year, the Centers for Medicare & Medicaid Services (CMS) releases updated lists of valid and excluded diagnosis codes based on the International Classification of Diseases (ICD). These lists, crucial for Section 111 NGHP Claim Input File submissions, are derived from ICD-10 codes used by healthcare providers for Medicare medical claims. It’s important to note that while many diagnosis codes are applicable across various claim types, some are specifically relevant to liability and workers’ compensation but not to no-fault scenarios. CMS conducts an annual review of ICD-10 codes to pinpoint those suitable for Section 111 NGHP reporting.
Diagnosis codes, once validated for Section 111 reporting, are maintained on these lists from year to year. Annual updates include the addition of new valid codes and revisions to the descriptions of existing ones, ensuring the lists remain current with the evolving landscape of medical diagnoses.
Exclusions and Specific Code Types
It’s important to recognize that not all ICD code types are included in the valid lists for Section 111 reporting. For instance, 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, are typically removed. These “Z” codes are generally excluded from Section 111 claim reports, mirroring the exclusion of “V” codes. However, “V” codes might be permissible in specific situations, such as identifying the Alleged Cause of Injury, Incident, or Illness. This is why “V” codes are not found on the excluded ICD-10 code list.
Furthermore, CMS has identified certain valid diagnosis codes that lack the necessary detail regarding the cause and nature of an illness, incident, or injury to be considered complete or adequate for Section 111 Claim Input File submissions. Consequently, these less informative diagnosis codes are placed on the excluded lists and will not appear on the valid lists for NGHP plan types. Using the correct and valid diagnosis codes ensures accurate and compliant Section 111 reporting, avoiding potential issues in claims processing and regulatory adherence.
