Decoding Valid and Excluded ICD-9 & ICD-10 Diagnosis Codes
Each year, CMS releases updated lists of valid and excluded diagnosis codes, derived from the International Classification of Diseases, Tenth Revision (ICD-10) and, historically, the Ninth Revision (ICD-9). These lists are crucial for ensuring compliance in Section 111 NGHP Claim Input File submissions. The valid lists detail the diagnosis codes that are acceptable for reporting, while the excluded lists specify codes that should not be used for particular plan types or reporting purposes. Notably, the valid lists also incorporate No-Fault Plan Type D exclusion indicators, providing further granularity for reporting accuracy.
The Annual Evolution of Diagnosis Code Lists
CMS undertakes an annual review of ICD-10 diagnosis codes to align them with the requirements of Section 111 reporting. This process ensures that the diagnosis codes used in claim submissions are relevant to liability and workers’ compensation situations. While many diagnosis codes remain consistent from year to year, the lists are dynamic. New valid codes are added to reflect the evolving landscape of medical diagnoses, and descriptions of existing codes may be revised to maintain clarity and accuracy.
It’s important to note that not all code types are included in the valid lists. For instance, ICD-9 codes that begin with “V” and ICD-10 codes that start with “Z,” which often relate to factors influencing health status rather than primary diagnoses of injury or illness, are typically excluded. These “Z” codes are considered less informative for Section 111 claim reporting in the context of establishing liability or responsibility. However, “V” codes might still find use in specific contexts, such as detailing the Alleged Cause of Injury, Incident, or Illness, explaining their absence from the excluded ICD-10 code list. Furthermore, certain diagnosis codes, even if technically valid, may be deemed insufficiently specific for Section 111 Claim Input File submissions and are therefore placed on the excluded lists to ensure data quality and relevance.
For RREs and agents involved in Section 111 reporting, staying updated with the latest valid and excluded diagnosis code lists is not just a matter of compliance, but a cornerstone of accurate and effective reporting practices. Accessing and understanding these lists is essential for navigating the intricacies of NGHP reporting obligations.
