CMS Updates List of ICD-9 and ICD-10 Codes Excluded from Mandatory Insurer Reporting

CMS Stack of PapersAs the Center for Medicare and Medicaid Services (CMS) has previously indicated in their Section 111 NGHP User Guide, Appendix I (Excluded ICD-9 Diagnosis Codes) and Appendix J (No-Fault Excluded Diagnosis Codes), there are several valid ICD-9 and ICD-10 diagnosis codes that may not be submitted as part of Mandatory Insurer Reporting (MIR) Alleged Cause of Injury, Incident, or Illness (Field 15) or the ICD Diagnosis Code 1-19 (Fields 18-36) on the Claim Input File Detail Record. If an ICD-9 diagnosis code is submitted in Field 15, it must be a code starting with the letter E that is not on the excluded list. If an ICD-10 diagnosis code is submitted in Field 15, it must be a code starting with the letter V, W, X, or Y that is not on the excluded list. If an ICD-9 diagnosis code is submitted in the ICD Diagnosis Codes 1-19 (Fields 18-36), it cannot start with the letter E, cannot start with the letter V, and it cannot be a code on the excluded list. If an ICD-10 diagnosis code is submitted in the ICD Diagnosis Codes 1-19 (Fields 18-36), it cannot start with the letter V, W, X, Y, or Z, and it cannot be a code on the exempt list.

Periodically, CMS will update their exemptions list. On May 23, 2016, the Centers for Medicare and Medicaid Services, Office of Financial Management, Financial Services Group, published a Technical Alert on Medicare Secondary Payer (MSP) Mandatory Reporting Provisions Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (See 42 U.S.C. 1395y(b)(7)&(b)(8)). The Technical Alert specifically addresses new excluded ICD-9 and ICD-10 diagnosis codes.

The Alert indicates that beginning January 2, 2017, the following International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) Diagnosis Codes will be added to the list of excluded MIR diagnosis codes:

  • 999.9 (Other and unspecified complications of medical care, not elsewhere classified)
  • T88.7XXA (Unspecified adverse effect of drug or medicament, initial encounter)
  • T88.7XXD (Unspecified adverse effect of drug or medicament, subsequent encounter)
  • T88.7XXS (Unspecified adverse effect of drug or medicament, sequela)
  • T88.8XXA (Other specified complications of surgical and medical care, not elsewhere classified, initial encounter)
  • T88.8XXD (Other specified complications of surgical and medical care, not elsewhere classified, subsequent encounter)
  • T88.8XXS (Other specified complications of surgical and medical care, not elsewhere classified, sequela)
  • T88.9XXA (Complication of surgical and medical care, unspecified, initial encounter)
  • T88.9XXD (Complication of surgical and medical care, unspecified, subsequent encounter)
  • T88.9XXS (Complication of surgical and medical care, unspecified, sequela)

As a result, these codes along with those found in Table I-1 (pages I1 to I11) and in Table J1 (pages J1 to J23) of the Section 111 NGHP User Guide will not be accepted in the Alleged Cause of Injury, Incident or Illness (Field 15) or in any ICD Diagnosis Code (Fields 18-36). In addition, updates to previously submitted records using these excluded codes, will also be rejected.

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