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Excluded ICD-10 Diagnosis Code Data for NGHP RREs

This document describes the purpose and layout of the file of Excluded ICD-10 Diagnosis Codes provided to responsible reporting entities (RREs) and agents for Section 111 Liability Insurance (Including Self-Insurance), No-Fault and Workers' Compensation Mandatory Reporting (Non-GHP or NGHP). Please see Section 6.2.5 in Chapter IV of the Section 111 NGHP User Guide for more information on the use of these codes for Section 111 reporting.

You can download the Excluded ICD-10 Diagnosis Codes by clicking on the file name below. To save a copy to your workstation, right-click a link and select "Save Target As." The data is provided in two formats, in a Microsoft Office Excel file (.xlsx) and in a MS-DOS text file (.txt). The file names are:

Purpose

CMS has determined that certain valid ICD-10 diagnosis codes do not provide enough information related to the cause and nature of an illness, incident or injury to be complete, useful, and/or adequate for Section 111 reporting and therefore must be excluded from Section 111 Claim Input File submissions. A list of these codes is provided in Appendix I of the NGHP User Guide and is referred to as the list of "Excluded ICD-10 and ICD-9 Diagnosis Codes". These codes will NOT be accepted in the Alleged Cause of Injury, Incident or Illness (Field 15) or in any of the ICD-10 Diagnosis Code 1-19 fields beginning in Field 18 of the Claim Input File Detail Record. Please see Section 6.2.5 in Chapter IV of the Section 111 NGHP User Guide for more information on the use of these codes.

In addition, to ensure claims are not improperly denied, CMS will no longer allow certain diagnosis codes to be posted within NGHP No-Fault MSP records if a diagnosis code is not related to a No-Fault Accident (Plan Insurance Type is equal to "D" in Field 51). No-Fault Claim Input File Detail Records that are submitted with one of these codes in the Alleged Cause of Injury, Incident, or Illness field (Field 15) or in any ICD Diagnosis field (Field 18 to Field 36) when the Plan Insurance Type is equal to "D" will be rejected. The record will be returned with an error corresponding to the field in which the excluded code was submitted, even if valid codes are supplied in one or more of any other ICD Diagnosis Code fields. Existing error code CI03 will be returned if an excluded code is submitted in Field 15 and error codes CI05-CI23 will be returned if an excluded code is submitted in Field 18 to Field 36. These codes are listed in Appendix J of the NGHP User Guide, referred to as the list of "No-Fault Excluded ICD-10 and ICD-9 Diagnosis Codes."

The downloadable files described here are a copy of the information provided in Appendixes I and J and are provided to make it easier for RREs and agents to incorporate these codes into their Section 111 reporting systems for use in editing Claim Input File Detail Records prior to submission. Use of the downloadable files is optional. RREs may refer directly to Appendix I or J or use the data files at their own discretion.

File Format

The Excel file is comprised of two spreadsheet tabs with two columns each. There is a column header in the first row. The first column contains the 7 character Excluded ICD-10 Diagnosis Codes. The second column contains the long description of the Excluded ICD-10 Diagnosis Codes found in the first column of the corresponding row. The first tab contains the excluded ICD-10 codes; the second contains the No-Fault excluded codes.

The file record layout of the MS-DOS text file is described in the table below. Each record has a carriage return line feed (CRLF) at its end. Records are of variable length. No field delimiters are used. The first section lists the excluded ICD-10 codes. That is followed by two blank lines and the second section, which lists the ICD-10 codes excluded for No-Fault records. A header row begins each section.

Field Length Starting Position Ending Position Description
Excluded ICD-10 Diagnosis Code 7 1 7 Excluded ICD-10 Diagnosis Codes from Appendix I or J of the NGHP User Guide.
Filler 1 8 8 Filled with a space.
Description Variable 10 Variable Description of Excluded ICD-10 Diagnosis Code from Appendix I or J of the NGHP User Guide.