Navigating the complexities of Section 111 reporting requires accurate and up-to-date information, especially when it comes to diagnosis codes. For Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) and their agents involved in liability insurance, no-fault, and workers’ compensation mandatory reporting, it’s crucial to utilize the correct International Classification of Diseases (ICD) codes. Each fiscal year, updated lists of valid and excluded diagnosis codes are released to ensure compliance and accuracy in reporting.
These essential diagnosis code lists, available for download in Excel (.xlsx) format, are derived from the ICD-10 codes that the Centers for Medicare & Medicaid Services (CMS) provides annually for Medicare medical claims. This ensures that healthcare providers and suppliers are using the most relevant diagnosis codes when submitting their claims. While many diagnosis codes are applicable across different scenarios, some are specifically relevant to liability and workers’ compensation cases but not to no-fault accidents or injuries. CMS undertakes 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 valid for Section 111 reporting, it remains on the valid list in subsequent years. The lists are dynamic, with new valid codes being added and descriptions of existing codes being revised annually to reflect the latest medical classifications and reporting requirements.
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 denote factors influencing health status and contact with health services, are typically removed from the valid lists. These “Z” codes, equivalent to the older “V” codes, are generally excluded from Section 111 claim reports. However, “V” codes may still have a role in specific situations, such as identifying the Alleged Cause of Injury, Incident, or Illness, which is why they are not included in the excluded ICD-10 code list. Furthermore, CMS identifies certain valid diagnosis codes that lack sufficient detail regarding the cause and nature of an illness, incident, or injury for comprehensive Section 111 Claim Input File submissions. These less informative diagnosis codes are then added to the excluded lists, ensuring they do not appear on the valid lists for NGHP plan types, maintaining the quality and relevance of reported data.
Using the correct List Of Diagnosis codes is paramount for accurate and compliant Section 111 reporting. Staying informed about the annual updates and understanding the nuances of valid and excluded codes is essential for all RREs and agents in the NGHP sector.
