To assist with compliance, CMS offers downloadable Excel files containing the most current valid and excluded ICD diagnosis code lists for the fiscal year 2025. These resources are essential for ensuring the accuracy of Section 111 reporting and can be accessed through the links provided below. The valid lists also specify No-Fault Plan Type D exclusion indicators, adding another layer of detail for precise reporting.
The Basis of Diagnosis Code Lists for Section 111 Compliance
These diagnosis code lists are not arbitrarily created. They are carefully derived from the comprehensive set of ICD-10 diagnosis codes that CMS utilizes annually for processing medical claims submitted by healthcare providers and suppliers to Medicare. While many diagnosis codes are relevant across different scenarios, some are specifically pertinent to liability and workers’ compensation claims but not applicable to no-fault accidents or injuries.
CMS conducts an annual review of ICD-10 codes to pinpoint those suitable for Section 111 NGHP Claim Input File Detail Record submissions. Once a diagnosis code is deemed relevant for Section 111 reporting, it remains on the valid lists in subsequent years. Each year, new valid codes may be added, and the descriptions of existing codes are updated to reflect the latest medical classifications and reporting needs.
It’s important to note that not all code types are included in the valid lists. For instance, ICD-9 codes starting with “V” and ICD-10 codes beginning with “Z,” which often represent factors influencing health status or encounters for specific purposes (similar to “Z codes” in ICD-10), are generally removed from the valid lists for Section 111 reporting. Although “Z codes” are typically excluded from claim reports, “V” codes might be used in specific situations, such as detailing 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, while technically correct, lack the necessary specificity to adequately describe the cause and nature of an illness, incident, or injury for Section 111 Claim Input File submissions. These less informative diagnosis codes are placed on the excluded lists, ensuring that only the most useful and detailed codes are used for NGHP plan types, thereby improving the quality and accuracy of Section 111 reporting.
