De-Mystify ICD-9 Coding for MMSEA Section 111 Reporting

Using Proper ICD-9 Codes Can Be Confusing

As of January 1, 2011, CMS required Responsible Reporting Entity (RRE) claim submissions to include valid Alleged Cause of Injury, Incident, or Illness ICD-9 ‘E’ Code and at least one valid ICD-9 Diagnosis Code. The previously utilized Description of Illness/Injury field had also been made unavailable.

The trend observed by CMS during this February’s MMSEA Section 111 Town Hall Teleconference had been that the most frequently incurred rejection error for the first quarter had been CI05 (missing or invalid Diagnosis code) followed by error CI03 (missing or invalid alleged cause of injury, incident or illness ICD-9 E Code).

RREs Face Challenges

So, why are so many RREs struggling with proper ICD-9 coding and what are ramifications of missing or invalid codes? Answers lie in the process, identification and application of valid codes.

ICD-9 is an acronym for International Classification of Diseases, ninth revision and is designed to promote international comparable statistics. Each October, CMS introduces a new list of revised codes which in part, is adopted for MMSEA Reporting January 1 of each year.

Originally, only the three most current lists of ICD-9 coding were to be utilized for reporting.  However, CMS has indicated (reinforced per the February 2011 Town Hall teleconference) that they will accept ‘non-excluded’ ICD-9’s from List 25 on forward. ‘Excluded ICD-9 Diagnosis Codes’ maybe found in Appendix H of the most recent MMSEA Section 111 NGHP User Guide.

The challenge in reporting has now become accurately identifying ICD-9 codes which best explain how the incident occurred, and most importantly, the diagnosis associated with the injury either consistent with the assumed on-going responsibility for medical (ORM) or accepted diagnosis released pursuant to settlement, judgment or award (TPOC, total payment obligation to the claimant).

Web-based Tools Available

CMS offers RREs computer based training modules which recommend utilization of medical provider billing as a starting point for selection of ICD-9’s but recognizes that RREs may not have received medical billing. In scenarios where billing is not available, CMS recommends ‘extrapolating’ codes from available reports.

Tools are available to search for ICD-9 coding, such as the CMS reference for valid ICD-9 diagnostic codes on the COBC Secure Website (RRE log in is required) or from vendors such as Gould & Lamb’s GL-Code tool, which is a searchable database of valid ICD-9 Alleged Cause of Injury E Codes and ICD-9 Diagnosis codes.

Valid Codes Key to Success

Why is valid ICD-9 coding important? Valid coding ensures successful MMSEA Section 111 reporting record acceptance but it’s also critical to Medicare processes. Medicare will utilize the ICD-9 coding reported to ensure that primary payment is not made regarding identified diagnoses. Likewise, the Medicare Secondary Payer Recovery Contractor (MSPRC) will pursue recovery where Medicare has made primary payment related to the identified diagnosis.

Looking ahead, CMS plans to implement their own further indexed version, ICD-10-CM, by October 2013. CMS has indicated that instructions and requirements for the use of ICD-10 codes will be provided at a later date and are not currently accepted.

Considering the financial exposure to the RRE for improper ICD-9 coding, it’s incumbent to the RRE or RRE claims administrator to develop processes and work flows are in place to ensure timeliness and accuracy in code selection.  Resolving operational issues now will best prepare the RRE and/or its claims administrators for upcoming challenges.

About the Author: John Miano is the Manager of Reporting Services for Gould & Lamb, LLC. His primary responsibility is directing the implementation of CMS Section 111 reporting programs for our clients. He has over 20 years experience in the Property and Casualty Insurance Industry and is currently an active committee member of the International Association of Industrial Accident Board Committees (IAIABC). He is also a former Executive Board Member of the Association of Workers Compensation Claim Professionals (WCCP) and is a Board Certified Workers Compensation claim adjuster (CWC).

Gould & Lamb is a global leader of MSA/MSP Compliance Services in the country, serving domestic and international insurance companies, third-party administrators and self-insured entities.

Click on the below GL-Code icon to access our ICD-9 search tool

Share This Article: