The Centers for Medicare and Medicaid Services (CMS) released an updated Section 111 NGHPUser Guide (Version 6.9, October 3, 2022) regarding non-group health plans (liability, no-fault and workers’ compensation) Section 111 reporting.
User Guide updates were made to Chapter IV (Technical Guidance) and Chapter V (Appendices). Section 111 excluded valid diagnosis codes that can be used for diagnosis reporting in 2023 and the SP31 Error.
A general overview of the NGHP User Guide (Version 6.9) updates are as follows:
Section 111 excluded/valid diagnosis codes for 2023
Excel spreadsheets of the excluded and valid diagnosis codes for 2023 are available for download at CMS.gov at https://www.cms.gov/medicare/coordination-benefits-recovery-overview/icd-code-lists.
According to CMS, “the diagnosis code lists are derived from ICD-10 diagnosis codes that CMS posts each year so that providers and suppliers utilize the applicable diagnosis codes when submitting medical claims to Medicare.
“CMS States, “ICD-9 codes beginning with the letter “V” and ICD-10 codes beginning with the letter “Z” are removed from the valid lists. ICD-9 “V” codes are equivalent to ICD-10 “Z” codes (e.g., factors influencing health status and contact with health services). These “Z” codes, therefore, are also excluded from Section 111 claim reports. However, a “V” code may be used in certain circumstances, such as to identify the Alleged Cause of Injury, Incident, or Illness, which is the reason “V” codes will not appear on the list of excluded ICD-10 codes.”
Additionally, CMS states it has “determined that certain valid diagnosis codes do not provide enough information related to the cause and nature of an illness, incident, or injury to be complete, useful, or adequate for Section 111 Claim Input File submissions. Therefore, these diagnosis codes are added to the excluded lists and will not be found on the valid lists for NGHP plan types.”
At Care Bridge International we believe these code lists have a broader application for the claims environment in terms of improving the usefulness of claims data and improving data integrity. Claims data is “messy,” and we are often involved in data clean up related to diagnosis codes as these codes are inherently inaccurate and do not explain the compensable body part or nature of the injury. As it relates to Section 111, the downstream effect of inaccurate codes can have a significant impact on the Medicare beneficiary and the parties, so the importance of accurate diagnosis coding cannot be understated.
What’s Old is New Again SP31 Error
Chapter V summary indicates that “the SP31 Error has been restored. RREs will receive this error code when submitting records with effective dates greater than 90 days (about 3 months)prior to Medicare entitlement (Appendix F). This functionality existed in the past and was removed and is now restored.
As there are no technical changes required at Care Bridge International, customers will not notice any impact.
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