The Centers for Medicare & Medicaid Services (CMS) provides annual updates to the valid and excluded diagnosis code lists for Section 111 Non-Group Health Plan (NGHP) reporting. These lists are crucial for Responsible Reporting Entities (RREs) and agents involved in liability insurance, no-fault insurance, and workers’ compensation mandatory reporting. Access the latest lists to ensure compliance and accurate claim submissions.
Background on ICD-9 and ICD-10 Diagnosis Codes
These diagnosis code lists are derived from the ICD-10 codes that CMS releases annually for healthcare providers and suppliers. The purpose is to standardize the diagnosis codes used when submitting medical claims to Medicare. Within these comprehensive code sets, certain diagnosis codes are specifically relevant to liability and workers’ compensation scenarios, while others are not applicable to no-fault accidents or injuries. CMS conducts a yearly 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. The annual updates primarily involve the addition of newly valid codes and revisions to the descriptions of existing codes to reflect the latest medical classifications and reporting requirements.
However, 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 represent factors influencing health status and contact with health services, are systematically removed from the valid lists. ICD-9 “V” codes are considered equivalent to ICD-10 “Z” codes in terms of their classification. Consequently, these “Z” codes are also excluded from Section 111 claim reports. It’s important to note an exception: “V” codes might be used in specific situations to identify the Alleged Cause of Injury, Incident, or Illness. This specific use case is why “V” codes are not included in the excluded ICD-10 code list, allowing for detailed reporting of injury causation when necessary.
Furthermore, CMS has identified certain valid diagnosis codes that, while technically valid, lack sufficient detail regarding the cause and nature of an illness, incident, or injury. These codes are considered incomplete, less useful, or inadequate for the detailed requirements of Section 111 Claim Input File submissions. As a result, these less informative diagnosis codes are added to the excluded lists and are intentionally omitted from the valid lists provided for NGHP plan types. This ensures that the diagnosis information submitted for Section 111 reporting is as precise and informative as possible, enhancing the accuracy and utility of the reported data.
