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.

As the most accurate and respected Section 111 MMSEA services provider in the MSP industry, since 2011, Optum Settlement Solutions’ MedicareConnect℠ has delivered Mandatory Insurer Reporting data to CMS on hundreds of thousands of workers compensation, no-fault, and liability claims. With multiple years of 99.99% error free responses from CMS, our MIR platform continues to deliver our clients comprehensive reliable information used to comply with MSP requirements, including using MIR data to resolve conditional payments and appropriately allocate for future set aside arrangements. For more information about our MedicareConnect products and services, as well as our SettlementComplete products and services, please contact us at 888.672.7674, or at contactus@helioscomp.com.

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About Rafael Gonzalez

As vice president of strategic solutions, Rafael Gonzalez serves as a thought leader on all aspects of Medicare and Medicaid compliance issues, including mandatory insurer reporting, conditional payments resolution, Medicare set aside allocations, CMS approval, and professional administration of Medicare set asides and special needs trusts. Prior to joining Helios, over the last 30 years, Rafael served as director of Medicare & Medicaid compliance and post settlement administration for Gould & Lamb in Bradenton, Florida. Before that, he served as chief executive officer for the Center for Lien Resolution, the Center for Medicare Set Aside Administration and the Center for Special Trusts Administration in Clearwater, Florida. Prior to that, he served as corporate counsel for FCCI Insurance, a workers’ compensation/property casualty insurance company in Sarasota, Florida. And before that, he practiced social security disability, workers’ compensation, longshore and personal injury law in Tampa, Florida. Rafael Gonzalez received his Bachelor of Science degree from the University of Florida and his Jurisprudence Doctorate degree from the Florida State University.

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