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CMS releases new NGHP Section 111 user guide (Version 5.7)

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 User Guide (Version 5.7, October 7, 2019) regarding non-group health plans (liability, no-fault and workers’ compensation). This updated guide replaces Version 5.6 (July 1, 2019).

Per CMS, the changes made in Version 5.7 relate to Chapter V – Appendices section. CMS’ updates concern the lists of Included and Excluded ICD Codes that will go into effect on January 1, 2020. In addition, CMS has posted new 2020 ICD code listings to the Section 111 website. 

Mika Baumeister Wpnoqo2plfa Unsplash (2)

In reviewing the new 2020 ICD Code listings, it is significant to note that there are some inaccuracies in the current listings. By way of example, there are a number of ICD-9 codes which appear twice on the valid ICD-9 code list, once as being accepted for all Insurance Types, and again as being excluded for No-Fault claims. Additionally, there is an ICD-9 code that is listed as being excluded for all Insurance Types, however, the ICD-9 code is also listed as being excluded for No-Fault only.

We have raised these inaccuracies to our contacts at CMS and are awaiting an update as to how they will be addressed. In the interim, if you have any questions please contact Mike Gibbon at michael.gibbon@verisk.com, or Jeremy Farquhar at jeremy.farquhar@verisk.com.


Mark Popolizio, J.D.

Mark Popolizio, J.D., is vice president of MSP compliance, Casualty Solutions at Verisk. You can contact Mark at mpopolizio@verisk.com.


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