For entities responsible for Non-Group Health Plan (NGHP) reporting under Section 111, using the correct Medicare Payable Diagnosis Codes is crucial for compliance. Each year, updated lists of valid and excluded ICD-9 and ICD-10 diagnosis codes are released by the Centers for Medicare & Medicaid Services (CMS) to guide liability insurance (including self-insurance), no-fault, and workers’ compensation mandatory reporting. These lists ensure accurate and Medicare-compliant claim submissions.
Understanding the Diagnosis Code Lists
These diagnosis code lists are derived from the ICD-10 codes used by Medicare for claim submissions. The Centers for Medicare & Medicaid Services (CMS) annually reviews ICD-10 codes to determine those applicable for Section 111 NGHP Claim Input File submissions. While many codes are relevant to liability and workers’ compensation, some are not appropriate for no-fault scenarios.
Diagnosis codes pertinent to Section 111 reporting are maintained on these lists year after year. Annual updates include the addition of new valid codes and revisions to existing code descriptions.
Code Exclusions and Special Cases
It’s important to note that not all code types are included. For instance, ICD-9 codes starting with “V” and ICD-10 codes starting with “Z,” which relate to factors influencing health status, are generally excluded from these lists for Section 111 claim reporting. However, “V” codes might be used in specific situations, such as identifying the cause of injury, and therefore are not on the excluded list. Furthermore, certain valid diagnosis codes that CMS deems insufficiently detailed for Section 111 claim submissions are also placed on the excluded lists.
Conclusion:
Utilizing the correct ICD-9 and ICD-10 diagnosis codes from the CMS’s annually updated lists is vital for compliant and accurate Section 111 reporting. These lists, derived from Medicare’s own claim processing standards, ensure that reported diagnosis codes are relevant, sufficiently detailed, and payable within the Medicare system for liability, no-fault, and workers’ compensation cases. Access the latest code lists from official CMS resources to ensure accurate and Medicare-compliant reporting.
