CMS Releases New MMSEA Section 111 NGGHP User Guide, version 4.3 – Six Policy Alerts Remain for Next Update
Roy Franco
October 15, 2014

Last week the Centers for Medicare & Medicaid Services (CMS) issued version 4.3 of its MMSEA Section 111 NGHP User Guide which can be accessed through this link. These changes were primarily driven by Congressional enactment of PAMA on April 1, 2014 which prohibits CMS from using ICD-10 codes on or before October 1, 2015. Prior to the law, CMS expected RREs to voluntarily submit ICD-10 codes after 4/1/2014, and required it after 10/1/2014.

The specific changes made were:

  • Change Request 12120: When implemented, RREs will not be allowed to report ICD-10 “Z” codes. These are now excluded from Section 111 claim reports (Chapters IV & V).
  • Change Request 12178: Missing excluded ICD-10 codes added to Appendix J, Chapter V.
  • Change Request 12373: Updated to reflect the delay of ICD-10 diagnosis code implementation from October 2014 to 2015 (Chapters IV & V).
  • Change Request 12590: For ICD-10 changes, field numbering/layout discrepancies were corrected in Table A-2 (Claim Input File Supplementary Information), Chapter V.
  • Change Request 12170: Two threshold error checks for Claim Input File were implemented in July 2011. These errors are related to the dollar values reported for both cumulative TPOC amounts and the No-Fault Limit (Chapter IV).
  • Change Request 12593: Reviewed to ensure that spouse references are gender-neutral according to DOMA.
  • Change Request 12636: The Appendix L alerts table has been removed and replaced with links to the Section 111 web site, which posts all current alerts and stores all archived alerts (Chapter V).
  • Change Request 12829: Updated CS filed numbers in Table F-4 (Claim Response File Error Code Resolution Table) to accommodate ICD-10 revisions (Chapter V).

Six CMS policy alerts remain outstanding and are expected to be incorporated in the next User Guide. These Alerts can be found at this link

1.  Change in Reporting of Medicare HICNs and SSNs for NGHP RREs

CMS has updated the way it will help Responsible Reporting Entities (RREs) identify a Medicare Beneficiary (MB) and for the purposes of reporting settlements, judgments, awards or other payments. Effective January 5, 2015, the data elements necessary for CMS to correctly identify a Medicare beneficiary as follows:

  • Last 5 digits of SSN
  • First Initial
  • Surname
  • Date of Birth
  • Gender

CMS highly recommends that RREs continue their due diligence to obtain the Claimant’s partial Social Security Number. In cases where a partial Social Security Number cannot be retrieved, one’s attempt at retrieving these items must be well documented. Model Language for this process has been provided by CMS for RREs to utilize. It is located in the Downloads section of the MIR for NGHP page.

2.  Changes to the CJ07 Error Code to Coincide with the new Reporting Threshold for Certain Liability Insurance (including Self-Insurance) Settlements, Judgments Awards, or Other Payments

Effective January 1, 2015, the CJ07 (Not reportable) edit will be returned on all Claim Input File Detail Records and Direct Data Entry (DDE) claim submissions that meet the following criteria:

  • If the most recent TPOC Date is on or between October 1, 2012 and September 30, 2014 and the cumulative TPOC Amount is less than or equal to $300; or
  • If the most recent TPOC Date is on or after October 1, 2014 and the cumulative TPOC Amount is less than or equal to $1000 (CMS, Centers for Medicare & Medicaid Services, 2014)

3.  Delay in transition from ICD-9-CM diagnosis codes to ICD-10-CM diagnosis codes for Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation

Due to PAMA (enacted in 04/01/14), ICD-10-CM diagnosis codes shall not be adopted and utilized prior to October 01, 2015, making ICD-9-CM diagnosis codes the required method. Below is a quick reference list of appropriate situations to utilize the ICD-9-CM and ICD-10-CM diagnosis codes created by CMS (CMS, Centers for Medicare & Medicaid Services, 2014).

PRIOR to October 1, 2015:

  • RREs may only submit ICD-9-CM diagnosis codes on their production Claim Input Files and
  • DDE submissions. The ICD Indicator field must contain a space or a ‘9’ on Claim Input File
  • Detail Records. The Diagnosis Code Indicator field must be set to ICD-9 for DDE submissions.
  • ICD-10-CM diagnosis codes will not be accepted on production Claim Input File Detail
  • Records or DDE submissions.
  • ICD-10-CM diagnosis codes will be accepted on test Claim Input File Detail Records.
  • The compliance flag, previously identified in the June 11, 2013 Alert, will not be returned if an
  • RRE submits an ICD-9-CM diagnosis code between October 1, 2014 and March 31, 2015.

BEGINNING October 1, 2015:

  • ICD-10-CM diagnosis codes will be required on all production Claim Input Files and DDE add and update records with a CMS Date of Incident (DOI) of October 1, 2015 and subsequent.
  • ICD-9-CM or ICD-10-CM diagnosis codes will be accepted on all add and update records with a CMS DOI prior to October 1, 2015.
  • The ICD Indicator field must contain a zero when ICD-10-CM diagnosis codes are submitted on Claim Input File Detail Records.
  • The Diagnosis Code Indicator field must be set to ICD-10 when ICD-10-CM diagnosis codes are submitted via DDE.

4.  Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation-Excluded Diagnosis Codes

CMS has determined that the ICD-10-CM “Z” diagnosis codes does NOT provide sufficient information regarding the cause and nature of an illness, incident or injury and thus, will be EXCLUDED from use, under the following:

a. Section 111 claim reports
b. Section 111 reporting
c. Alleged Cause of Injury, Incident, or Illness (Field 15)
d. Any ICD Diagnosis Code field beginning in Field 18

On a separate, yet related note, ICD-10 diagnosis codes with the letter “V,” “W,” “X,” or “Y” may only be reported in Field 15, IF AND ONLY IF, they do NOT appear in the NGHP User Guide under “Excluded Diagnosis Code List.Furthermore, codes are considered invalid when they are in any of the ICD Diagnosis Code fields beginning in Field 18 (CMS, Centers for Medicare & Medicaid Services, 2014).

5.  Change in Reporting Threshold for Certain Liability (including Self-Insurance) Settlements, Judgments Awards, or Other Payments

Everything below references reporting thresholds pertaining to Certain Liability (including self-insurance) settlements, judgments, awards, or other payments

  • For TPOCs dated ON or BEFORE October 01, 2013, the current mandatory reporting threshold is $2,000+
  • For TPOCs dated October 01, 2014 and AFTER is increasing from $300 to $1,000. If the most recent TPOC date is ON or AFTER October 01, 2014, and the cumulative TPOC Amount is greater than $1,000, the TPOC(s) must be reported no later than the end of the RRE’s submission timeframe in the quarter beginning January 01, 2015.
  • Error code CJ07 has NOT been updated to reflect this change. Further guidance to come at a later date that will coincide with the new reporting threshold of $1,000.

6.  Liability Insurance (Including Self-Insurance):Exposure, Ingestion, and Implantation Issues and December 5, 1980

The document produced by CMS provides examples of situations in which the MSP provision for liability insurance (including self-insurance) effective December 05, 1980, will cause Medicare to assert a recovery claim against settlements, judgments, awards or other payments as well as the MMSEA Section 111 rules that must be followed.

Furthermore, it includes of ALL criteria that MUST be met in order to avoid Medicare asserting a recovery claim against a liability insurance (including self-insurance) settlement, judgment, award, or other payment.

Click here for examples of the policy related to December 05, 1980 please refer to the pdf created by CMS (CMS, Centers for Medicare & Medicaid Services, 2014).

The above 6 topics of interest are summaries of the latest modifications that will be included in the next version of the MMSEA Section 111 NGHP User Guide that has yet to be published. It is encouraged that you read the original documents found in this link, so that you may have an absolute understanding of how these changes will affect you in the future.