The Hidden Risks behind reporting those Pesky ICD 09 Codes under Mandatory Insurer Reporting (Updated)

Medicare updated the Section 111 Mandatory Insurer Reporting by adding specific guidance in the most recent release of the NGHP User Guide to clarify that ICD 09 Codes are not to be used lightly by the Responsible Reporting Entity:

"The requirements for reporting ICD-9 diagnosis codes in Section 11.2.5 were updated to clarify that ICD-9 diagnosis codes submitted should be those that reflect the illnesses/injuries claimed and/or released by the settlement, judgment, award, or for which ORM is assumed"

Mandatory insurer reporting requires each claim submitted by the RRE under MMSEA have at least one ICD 09 event code and one ICD 09 diagnosis code in order to report a claim, but despite the sometimes cavalier attitude displayed by CMS during the town hall meetings toward selecting the appropriate code there are two significant dangers and potential cause of action on behalf of the claimant.

The ICD 09 codes the RRE provides to Medicare when they report serve two purposes.  The first is to deny payments where another insurer should pay primary.  This is accomplished by using the code to deny specific provider claims.  If the ICD 09 codes are incorrect, or too general, the claimant (beneficiary) will be denied coverage and may have a cause of action against the insurer, plaintiff attorney or carrier that provided those codes.  (Read the related article "Workers' Comp and multiple TPOCs).  Although, Medicare has stated in some of their NGHP Section 111 town hall meetings that codes provided by insurers and carriers will not be used to deny claims, the question then arises: How are they going to deny claims of a Pro Se Claimant?

Medicare also uses ICD 09 codes supplied under the MMSEA reporting to sort out which claims should be the responsibility of the primary payer's plan.  If Medicare pays conditionally in the case of a liability plan or mistakenly under no-fault or workers' compensation, they will demand a reimbursement from the primary plan.  Obviously, a poor choice of ICD 09 codes will result in improper demands for reimbursement.  The primary payer will have to expend extra energy to dispute the claims on the demand, especially if they unintentionally accepted the responsibility in the first place.

Bottom Line:  Competently designed MMSEA software (see Medicare Consul Services) will prevent you from reporting invalid ICD 09 Codes, but the Responsible Reporting Entity must take great care in choosing which ICD 09 codes to report under Section 111 Mandatory Insurer Reporting.  Don't deny your claimant proper treatment and don't add an additional burden to your claims department.