The Importance of Using Accurate Diagnosis Codes in Section 111 Reports

10.22.2019 Blog

In 2015, CMS announced it would be requiring responsible reporting entities (RREs) to begin using ICD-10 diagnosis codes in Section 111 reports for accidents occurring on or after October 1, 2015.  There are several benefits to using ICD-10 codes compared to ICD-9 codes, namely improved specificity and hierarchy of diagnoses.  Although ICD-10 codes are required for accidents on or after October 1, 2015, RRE’s may also use ICD-10 codes for reporting accidents before then, as long as all codes are reported as ICD-10.

Diagnosis codes in Section 111 reporting primarily serves two purposes:

  1. It allows for the accurate coordination of benefits for claims submitted to Medicare for a claimant’s treatment; and
  1. It facilitates accurate identification of conditional payments related to a work injury.

These two purposes illustrate the importance of accurately reporting ICD codes.

In the first situation, when CMS receives claims for prospective treatment, it compares the diagnosis codes submitted in the request to those contained in the Section 111 report.  If the codes for the requested treatment are similar to those in the Section 111 report, CMS may deny the prospective treatment.  Thus, inaccurate reporting could result in unwarranted denial of treatment that has no relation to the work injuries, which could create unnecessary friction between the claims handler and the Claimant.

Reporting accurate and specific ICD codes also promotes effective and efficient conditional payment investigations.  CMS does not just search for the specific ICD code; rather, it will include many similar codes that cover the same body parts or similar conditions.  Therefore, reporting codes for specific body parts can reduce the chance of CMS including unrelated claims in a conditional payment notice or demand.

When selecting which codes to report, RREs should avoid blindly reporting codes listed on EOBs or medical records, as providers may include conditions beyond those involved in the work accident.  An example commonly seen is the inclusion of codes for unrelated hypertension or diabetes which appeared on the EOBs from the bills from the initial treatment.  RREs should also periodically update their Section 111 reports to account for any new, updated or recently denied body parts or conditions.

Section 111 reports allow RREs to report up to 19 different diagnosis codes and one external cause of injury code.  For catastrophic injuries or accidents involving multiple body parts, the RRE should include at least one diagnosis code per body part.

Specificity is key in reporting ICD codes.  For example, if the accepted condition involves a left knee meniscal tear, RRE’s should report a code like “M23307 – Other meniscus derangements, unspecified meniscus, left knee,” rather than general or non-specific codes like “S8982XS – Other specified injuries of left lower leg, sequela.”  Reporting the latter could yield denial of treatment for conditions such as unrelated DVT or ankle conditions, and can lead to conditional payment recovery for those conditions, as well.

Of course, the level of specificity must be determined on a case-by-case basis and will vary depending on the circumstances of the claim and the injuries involved.  However, with over 70,000 ICD-10 codes accepted by Section 111 reporting, RRE’s should be able to find the right code for almost any work-related accident or injury.  ICD-10 allows RRE’s to be quite granular in identifying the nature, location, and status of the injury.  For instance, “S0511X – Contusion of eyeball and orbital tissues, right eye, initial encounter,” “S91152A – Open bite of left great toe without damage to nail, initial encounter,” and “S30867A – Insect bite (nonvenomous) of anus, initial encounter,” are all valid codes under Section 111.

There are also very specific “external cause of injury” codes that can cover nearly any situation.  There is “W2202XD – Walked into lamppost, subsequent encounter,” “V0490XA – Hit by a Mack Truck,” “V00151A – Fall from heelies, initial encounter,” and “W6101XA – Bitten by parrot, initial encounter”.  In the event “bitten by parrot” does not sufficiently capture the situation, there is also “W6112XD – Struck by macaw, subsequent encounter.”

Finally, RRE’s should confirm that the diagnosis codes are entered in the proper format, and not an excluded code.  CMS publishes guidance materials detailing the requirements for reporting ICD codes under Section 111, as well as a list of valid codes.

Overall, accurate reporting of diagnosis codes can help reduce the likelihood of two inconvenient situations that may arise when handling a workers’ compensation claim involving a Medicare beneficiary.  It can reduce the improper denial of treatment that is unrelated to the work injury, which will avoid calls from disgruntled claimants or their attorneys.  It will also reduce the likelihood that non-industrial treatment is alleged as a conditional payment, saving claims handlers time and other resources in addressing conditional payments.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information. Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.