CMS Expands on Definition of Cumulative Injury for Section 111 NGHP Reporting
On July 1st, 2024, the Centers for Medicare and Medicaid Services (CMS) published an updated Section 111 Reporting, NGHP User Guide Version 7.6. This guide includes significant updates and clarifications that impact reporting requirements.
Introduction and Overview
Chapter 2 states:
“Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements.”
Additionally, CMS made a minor update to Technical Information Chapter 6, Sections 6.3.3 and 6.6.5, adding information on how to resolve TIN address errors.
Sanderson Commentary
It is important to note that cumulative trauma should be examined separately from a specific injury when trying to determine the date of incident. Cumulative trauma injuries develop over time and are not a specific acute trauma (e.g., an administrative assistant who develops carpal tunnel syndrome after years of typing). A specific date of injury/incident (DOI) may be difficult to ascertain in these situations. When reporting cumulative trauma claims, be sure to reference the definition CMS provides in the NGHP User Guide as it may differ from what has been established for the claim.
The NGHP User Guide defines the CMS DOI for a cumulative trauma injury as:
The earlier of the date that treatment for any manifestation of the cumulative injury began when such treatment preceded formal diagnosis; or
The first date that formal diagnosis was made by any medical practitioner.
Technical Information on TIN Address Errors
Regarding the TIN address, Responsible Reporting Entities (RREs) should pre-validate submitted addresses to prevent validation issues that hinder the processing of claim data. CMS has suggested utilizing ZIP Code™ Lookup | USPS to confirm appropriate street addresses. If updates are necessary after the initial TIN Reference File is successfully processed, the RRE would send updates only if there are changes or additions to make. Subsequent Claim Input Files do not need to be accompanied by a TIN Reference File unless changes to previously submitted TIN/Office Code information must be submitted or new TIN/Office Code combinations have been added. Only new or changed TIN records need to be included on subsequent submissions.
If you have any questions regarding Cumulative Injury, the TIN Reference File, or any other Section 111 inquiries, please contact Heather Traxler.
