Navigating the complexities of Section 111 reporting requires a thorough understanding of diagnostic codes. As entities responsible for Non-Group Health Plan (NGHP) reporting, including liability insurance, no-fault, and workers’ compensation, it is crucial to utilize the correct International Classification of Diseases (ICD) codes. This guide provides an overview of the Diagnostic Codes List for Section 111 reporting, ensuring accurate and compliant submissions.
Understanding the landscape of diagnostic codes is essential for entities involved in Section 111 reporting. These codes, primarily ICD-9 and ICD-10, are fundamental for detailing diagnoses in medical claims. The Centers for Medicare & Medicaid Services (CMS) annually releases updated lists of valid and excluded ICD diagnosis codes to facilitate accurate reporting. These lists are specifically tailored for Section 111 NGHP Claim Input File Detail Record submissions.
The foundation of these lists comes from the ICD-10 diagnosis codes that CMS regularly updates for Medicare claims processing. However, for Section 111 reporting, the applicability of certain codes varies. While some codes are relevant to liability and workers’ compensation cases, they may not be appropriate for no-fault accident or injury scenarios. CMS conducts an annual review of ICD-10 codes to pinpoint those suitable for Section 111 NGHP reporting.
Once a diagnostic code is deemed relevant for Section 111 reporting, it becomes a permanent fixture on the valid codes list. Each year, the lists are updated to incorporate newly valid codes, and revisions are made to the descriptions of existing codes to maintain accuracy and reflect the latest medical classifications.
It’s important to note that not all code types are included in the valid diagnostic codes list. For instance, ICD-9 codes that begin with “V” and ICD-10 codes starting with “Z,” which often represent factors influencing health status or encounters with health services, are typically excluded from the valid lists. ICD-9 “V” codes are analogous to ICD-10 “Z” codes in many cases. Consequently, “Z” codes are generally not permitted in Section 111 claim reports. Despite this general exclusion, “V” codes might be acceptable in specific situations, such as when 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 otherwise valid diagnostic codes that lack sufficient detail about the cause and nature of an illness, incident, or injury. These less informative diagnostic codes are placed on the excluded lists and will not appear on the valid lists for NGHP plan types, ensuring a higher standard of data quality for Section 111 reporting.
By adhering to the CMS-provided diagnostic codes list, NGHP responsible reporting entities can ensure compliance and accuracy in their Section 111 submissions. Utilizing the valid diagnostic codes list is a critical step in the mandatory reporting process.
