Injury Information

Select the insurance plan type from the drop-down list that the claim is being filed under. Values are No-Fault, Workers’ Compensation, or Liability.

Note: The CMS definition of No-Fault insurance is different than the industry definition, which is generally limited to certain automobile insurance. “No-Fault insurance” means insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for the accident. This insurance includes but is not limited to automobiles, homeowners, and commercial plans. It is sometimes called "medical injury protection” or "medical expense coverage." See 42 CFR 411.50.

If you are updating an existing claim that was previously accepted (i.e., the disposition is 01 or 02), this field will be disabled. If you need to correct the insurance type on a previously submitted and accepted claim, you must delete the previously reported record and then submit a new claim with the correct insurance type.

Enter the Date of Incident (DOI) as defined by CMS: For an automobile wreck or other accident, the DOI is the date of the accident. For claims involving exposure (including, for example, occupational disease and any associated cumulative injury) the DOI is the date of first exposure. For claims involving ingestion (such a recalled drug), it is the date of first ingestion. For implants, it is the date of the implant (or date of the first implant if there are multiple implants). Date should be entered as MM/DD/CCYY.

Note: The Date of Injury must be entered before you will be permitted to perform a diagnosis code lookup.

If you are updating an existing claim that was previously accepted (i.e., the disposition is 01 or 02), this field will be disabled. If you need to correct the DOI on a previously submitted and accepted claim, you must delete the previously reported record and then submit a new claim with the correct DOI.

Select ICD-9 or ICD-10 to identify the type of diagnosis codes submitted on the claim. 

Remember that you may only use ICD-9 codes for any Date of Incident (DOI) that is earlier than 10/1/2015. ICD-10 codes are accepted for any DOI but are required for DOIs as of 10/1/2015 and later.

The Diagnosis Code Indicator selected must correspond to all of the diagnosis codes submitted on the claim. You cannot submit a combination of ICD-9 and ICD-10 diagnosis codes on one claim.

You will not be allowed to change the ICD indicator if any diagnosis code has already been applied to the record. If you need to change the selected Diagnosis Code Indicator, you must first delete all existing diagnosis codes before you will be allowed to change the Diagnosis Code Indicator.

Notes: 

• The Diagnosis Code Indicator must be entered before you will be permitted to perform a diagnosis code lookup.
• Some ICD-9 and ICD-10 diagnosis codes cannot be submitted when the MSP record type is D-Automobile Insurance, No Fault. See valid and excluded ICD code lists on CMS.gov, at https://www.cms.gov/medicare/coordination-benefits-recovery/overview/icd-code-lists. This link is also available through the Reference Materials section of the navigation bar.

This field is required.

Follow these steps to add either an ICD-9 or ICD-10 code for the alleged cause of injury (optional). 

1.   Make sure you have selected a Diagnosis Code Indicator (ICD-9 or ICD-10).

2.  Click Add to open the Cause of Injury Diagnosis Code Lookup dialog.

If you are replacing a code, click Add and select a different code. The new code will replace the existing code. Only one COI diagnosis code can be entered.

3.   If you know the code, enter it in the Apply Code field and click Apply Code.

If you selected ICD-9 for the Diagnosis Code Indicator, the system will append the “E” that precedes all ICD-9 E Codes for you if it is not entered. Do not enter a decimal point. For example code E812.0 can be entered as "8120" or "E8120." The code will be validated when you click the Continue button to go to the next page, or when you "Save" your claim. If you selected ICD-10 for the Diagnosis Code Indicator, you must enter a diagnosis code that begins with any of the following characters: “V,” “W,” “X,” or “Y.”

4.   To conduct searches, enter a full or partial code number in the Diagnosis Code field, or enter keywords in the Diagnosis Keywords field; then click Search.

The results will appear below the fields. 

The search is not case sensitive. The application will search the descriptions associated with diagnosis codes in the database and return the codes that contain the text in their descriptions. If you selected ICD-9 for the Diagnosis Code Indicator, only codes beginning with "E" will be returned. If you selected ICD-10 for the Diagnosis Code Indicator, only codes that begin with the first character entered in the diagnosis code field will be returned.

5.   From the results list, select a radio button for a code and click Continue.

The dialog closes and the diagnosis code appears on the Claim Information page.

All ICD-10 codes beginning with the letter "Z" (e.g., factors influencing health status and contact with health services) are considered invalid for Section 111 reporting and should be excluded. You will not be allowed to enter these codes in this field.

Enter up to 19 diagnosis codes describing the alleged injury/illness.

1.   Make sure you have selected a Diagnosis Code Indicator (ICD-9 or ICD-10).

2.   Click Add to open the Diagnosis Code Indicator [ICD-X] dialog.

3.   If you know the codes you want, enter them one at a time in the Add Diagnosis field and click Add Diagnosis.

4.   To conduct searches, enter a full or partial code number in the Diagnosis Code field, or keywords in the Diagnosis Keywords field; then click Search.

The results will appear below the fields.

5.   Click to check one or more code checkboxes; then click Continue.

The dialog closes and the diagnosis codes appear on the Claim Information page. 

To remove a code, click the delete icon (X) under the Remove column on the Claim Information page.

Under special circumstances some liability and workers’ compensation claims do not have an injury associated with them. If a claim is required to be reported where this is the case, the code NOINJ may be entered in both the Alleged Cause of Injury Diagnosis Code field and the regular Diagnosis Code field. This code may not be used in combination with any other diagnosis code. See the CMS website for more guidance on this topic.