Navigating the complexities of Section 111 reporting requires a comprehensive understanding of diagnosis codes. For Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) and their agents, accurate reporting is crucial, especially concerning liability insurance, no-fault, and workers’ compensation mandatory reporting. This guide delves into the essential aspects of ICD-9 and ICD-10 diagnosis codes as they pertain to Section 111 compliance.
The Centers for Medicare & Medicaid Services (CMS) provides annual updates to the diagnosis codes that are valid and excluded for Section 111 NGHP Claim Input File submissions. These lists, derived from ICD-10 diagnosis codes used for Medicare medical claims, are vital for ensuring accurate reporting. It’s important to note that while some diagnosis codes are applicable to liability and workers’ compensation scenarios, they may not be relevant for no-fault accidents or injuries. CMS undertakes an annual review of ICD-10 codes to pinpoint those suitable for Section 111 NGHP Claim reporting.
Once diagnosis codes are approved for Section 111 reporting, they remain on the valid lists in subsequent years. These lists are dynamic, with new valid codes being added and descriptions of existing codes being revised annually to reflect the most current medical classifications.
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 typically excluded from the valid lists for Section 111 claim reports. While “Z” codes are generally excluded, “V” codes might be used in specific situations, such as identifying 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 lack sufficient detail regarding the cause and nature of an illness, incident, or injury for complete and effective Section 111 Claim Input File submissions. Consequently, these diagnosis codes are placed on the excluded lists and will not appear on the valid lists for NGHP plan types.
For the latest fiscal year, it is recommended to download the 2025 valid and excluded ICD diagnosis code lists in Excel (.xlsx) format, which are typically made available by CMS. These resources ensure that RREs and agents are using the most up-to-date and accurate Medicare Diagnosis Codes for Section 111 reporting, facilitating compliance and minimizing reporting errors. The valid lists also incorporate No-Fault Plan Type D exclusion indicators, adding another layer of specificity to guide accurate reporting practices. Using these resources effectively is key to navigating medicare diagnosis codes in Section 111 reporting.
