For entities responsible for Non-Group Health Plan (NGHP) reporting, including liability insurance, no-fault, and workers’ compensation, it is crucial to understand the valid and excluded diagnosis codes as per Section 111 requirements. The Centers for Medicare & Medicaid Services (CMS) provides annual updates to these codes to ensure accurate medical claims processing and reporting.
Accessing the Latest Diagnosis Code Lists
The most current lists of valid and excluded ICD diagnosis codes for Section 111 reporting are available for download in Excel format (.xlsx). These lists are essential resources for Responsible Reporting Entities (RREs) and their agents to maintain compliance. Within the valid code lists, you will also find No-Fault Plan Type D exclusion indicators, providing further clarity for specific reporting scenarios.
The Basis of Diagnosis Code Lists for Section 111
These diagnosis code lists are derived from the ICD-10 diagnosis codes that CMS publishes annually for Medicare providers and suppliers. This ensures that the codes used for Section 111 NGHP Claim Input File Detail Record submissions are consistent with those used in Medicare medical claims. It’s important to note that while some diagnosis codes are appropriate for liability and workers’ compensation claims, they may not be applicable to no-fault accidents or injuries. CMS undertakes an annual review of ICD-10 codes to determine their suitability for Section 111 NGHP reporting.
Once a diagnosis code is deemed valid for Section 111 reporting, it generally remains on the valid list 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 evolving medical landscape.
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 denote factors influencing health status and contact with health services, are typically excluded from the valid lists. The exclusion of “Z” codes extends to Section 111 claim reports. Despite this general exclusion, “V” codes might be used in specific situations, such as when identifying the Alleged Cause of Injury, Incident, or Illness. This specific use case explains why “V” codes are not included in the excluded ICD-10 code list.
Furthermore, CMS has identified certain valid diagnosis codes that, while technically valid, do not offer sufficient detail regarding the cause and nature of an illness, incident, or injury for effective Section 111 Claim Input File submissions. These less informative diagnosis codes are added to the excluded lists and are consequently not present on the valid lists for NGHP plan types. Understanding these exclusions is as important as knowing the valid codes to ensure accurate and compliant Section 111 reporting.
