Navigating the complexities of medical coding is crucial, especially when it comes to compliance and accurate reporting. For entities involved in Non-Group Health Plans (NGHPs) and Section 111 reporting, understanding the valid ICD-9 and ICD-10 diagnosis codes is essential. These codes are vital for reporting liability insurance, no-fault insurance, and workers’ compensation claims accurately.
Each year, the Centers for Medicare & Medicaid Services (CMS) releases updated lists of valid and excluded ICD diagnosis codes. These lists, initially designed for Medicare medical claims, are adapted for Section 111 NGHP Claim Input File Detail Record submissions. This adaptation ensures that the diagnosis codes used are relevant to liability and workers’ compensation scenarios, while excluding those applicable only to no-fault incidents.
The annual review process by CMS is thorough. They examine ICD-10 codes to pinpoint those suitable for Section 111 reporting. Once a diagnosis code is deemed valid for Section 111 purposes, it remains on the list in subsequent years. While new valid codes are added annually, descriptions of existing codes may also be revised to reflect the latest medical understanding and reporting needs.
It’s important to note that not all code types are included in the valid lists. For example, ICD-9 codes starting with “V” and ICD-10 codes beginning with “Z,” which often denote factors influencing health status rather than specific diagnoses, are generally excluded. These “Z” codes, similar to the “V” codes, are typically not appropriate for Section 111 claim reports. However, “V” codes can be used in specific situations, like identifying the cause of injury, which is why they are not on the excluded ICD-10 list entirely.
Furthermore, CMS identifies certain valid diagnosis codes that, while technically correct, lack the specificity needed for Section 111 Claim Input File submissions. These codes, deemed incomplete or inadequate for detailed reporting on the nature of an illness, incident, or injury, are placed on the excluded lists. Consequently, they will not appear on the valid lists for NGHP plan types. For those working in home care settings and dealing with ICD-9 coding for various patient conditions that might fall under Section 111 reporting, staying updated with these valid and excluded lists is critical for accurate claim submissions and compliance.
