For entities responsible for Non-Group Health Plan (NGHP) reporting, including liability insurance, no-fault, and workers’ compensation, staying compliant with Section 111 mandatory reporting is crucial. A key component of this compliance involves utilizing the accurate and up-to-date diagnosis codes. Each fiscal year, updated lists of valid and excluded diagnosis codes, based on both ICD-9 and ICD-10 classifications, are made available to ensure accurate reporting.
Accessing the Latest Diagnosis Code Lists
To simplify the process, the Centers for Medicare & Medicaid Services (CMS) provides downloadable lists of valid and excluded ICD diagnosis codes in Excel format (.xlsx). These lists are essential resources for 2025 reporting and beyond. You can access these lists through the links provided by CMS, which are typically updated annually. The valid lists also include specific No-Fault Plan Type D exclusion indicators, adding another layer of precision to your reporting.
The Basis for Diagnosis Code Lists in Section 111 Reporting
These Diagnosis Code Lists are not arbitrarily generated. They are carefully derived from the comprehensive set of ICD-10 diagnosis codes that CMS utilizes for Medicare medical claims. This ensures consistency and alignment with established healthcare coding standards. While many diagnosis codes are broadly applicable, some are particularly relevant to liability and workers’ compensation scenarios but not appropriate for no-fault accident or injury reporting.
CMS undertakes an annual review of ICD-10 codes to pinpoint those suitable for Section 111 NGHP Claim Input File Detail Record submissions. This meticulous process ensures that the codes used for reporting are relevant and contribute to meaningful data collection.
A significant aspect of these lists is their continuity. Once a diagnosis code is approved for Section 111 reporting, it generally remains on the valid list in subsequent years. The annual updates primarily focus on incorporating newly validated codes and refining the descriptions of existing codes to maintain clarity and accuracy.
Important Exclusions from Valid Diagnosis Code Lists
It’s important to note that not all code types are included in the valid lists. For instance, ICD-9 codes that begin with the letter “V” and their ICD-10 counterparts, which start with “Z,” are systematically removed from the valid lists. ICD-9 “V” codes and ICD-10 “Z” codes represent factors influencing health status and contact with health services. Their exclusion from Section 111 claim reports is a deliberate decision by CMS to ensure the reported codes are directly related to the injury or illness being claimed.
However, it’s worth mentioning that “V” codes are not entirely absent from Section 111 considerations. They may still be used in specific situations, such as when identifying the Alleged Cause of Injury, Incident, or Illness. This nuanced application is why “V” codes do not appear on the excluded ICD-10 code list, despite the general exclusion of “Z” codes.
Furthermore, CMS has identified certain valid diagnosis codes that, while technically correct, lack the necessary specificity for Section 111 Claim Input File submissions. These codes are deemed to be insufficiently informative regarding the cause and nature of an illness, incident, or injury. Consequently, these less specific diagnosis codes are added to the excluded lists, ensuring that only the most pertinent and detailed codes are utilized for NGHP plan type reporting.
By adhering to these annually updated valid and excluded diagnosis code lists, NGHP responsible reporting entities can ensure compliance, accuracy, and meaningful data submission for Section 111 reporting requirements.
