Proceed At Your Own Risk: Failure To Properly Use ICD-10 Codes

CMS has required the use of ICD-10 Diagnosis Codes in Section 111 reporting for incidents occurring after October 1, 2015 for over four years. The use of proper diagnosis codes by responsible reporting entitles (RREs) in their Section 111 reporting serves two primary purposes – 1) it allows for the accurate coordination of benefits for claims submitted to Medicare for the claimant’s treatment; and 2) it enables accurate identification of conditional payments associated with the work-related injury.

It is vital that the RRE not simply report the codes listed on the EOBs or contained in medical reports, as they may include injuries not associated with the work injury. Section 111 reports should also be routinely updated to account for any new, updated or denied body parts.

Section 111 reports allow for 19 different diagnosis codes and one external cause of injury code. RREs should make sure to include at least one diagnosis code per injured body part. While specificity is critical in reporting diagnosis codes, the level of specificity employed is done on a case by case basis and will change depending on the nature of the claim and injuries.

However, with Section 111 reporting over 70,000 ICD-10 codes, it should not be a problem finding the right code for the work-related accident and injury at issue. There are also very specific cause of injury codes for nearly any situation. Finally, make sure that the ICD-10 codes are entered in the proper format. CMS has guidance materials online for reporting ICD-10 Codes and a list of valid codes.

Accurate reporting of diagnosis codes is key in helping reduce the chance of an improper denial of treatment that is not related to the work injury and any confusion regarding conditional payments.

So, in short, taking the time to ensure that proper codes are used in Section 111 reporting will save you time and potential headaches down the road and not to mention an angry client who wants to know why treatment they are supposed to receive has been denied. Remember the old adage – Measure twice, cut once.