CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from Deborah Marsh, senior content specialist for AAPC, a training and credentialing association for the business side of health care.

On Sept. 1, 2019, Anthem Blue Cross posted news about a claim editing update to remove conflicts between Excludes1 and Excludes2 notes. While the announcement does not provide details about the edit, it does provide an opportunity to discuss how Excludes1 and Excludes2 notes affect ICD-10 coding and their role in denial prevention.

The Excludes1 basics

In short, ICD-10 includes an Excludes1 note when two conditions (with separate codes) can’t occur together. The example given in the 2020 ICD-10-CM Official Guidelines for Coding and Reporting, effective Oct. 1, 2019, is a congenital form and an acquired form of the same condition. These notes may appear in places other than the code level, such as at the three-character category level, so coders must check for all possible notes that apply to the code.

As an example, M20 Acquired deformities of fingers and toes is at the category level. It is not a complete, reportable code. But there are Excludes1 notes at this level, telling you not to report the following conditions and codes alongside any code beginning with M20:

• Acquired absence of fingers and toes (Z89)
• Congenital absence of fingers and toes (Q71.3, Q72.3)
• Congenital deformities and malformations of fingers and toes (Q66, Q68-Q70, Q74).

The Excludes2 basics

In contrast to Excludes1, Excludes2 appears when a code is not appropriate for a specific condition, and you should look elsewhere to code that excluded condition. If the patient has both conditions, you may report both codes together. Again, coders must check all possible places these notes may appear, such as chapter, block, category, subcategory and code.

As an example of Excludes 2, I10 Essential (primary) hypertension has a note that lets you know that if the essential hypertension involves brain vessels, you should use a code from I60-I69 instead because I10 does not represent that condition. But if the patient is diagnosed with both essential hypertension and essential hypertension involving vessels of the brain, it is acceptable to report both I10 and a code from I60-I69 on the same claim. In the code set, the note appears like this under I10:

Excludes2: essential (primary) hypertension involving vessels of brain (I60-I69).

Excludes1 has an exception

When applied to claims, Excludes1 notes have proved to have some glitches. Excludes1 notes exclude conditions rather than codes from being reported together. If multiple conditions fall under the same code, then some conditions may merit Excludes1 while others don’t.

Recognizing this, the parties that develop ICD-10 posted advice in October 2015 explaining that there may be circumstances when it is appropriate to report two codes together despite being subject to an Excludes1 note. A version of that exception is now in the Official Guidelines, I.a.12.a, quoted below:

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for “sleep related teeth grinding (G47.63),” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.

Code 1 may have both Excludes1 and Excludes2 for code 2

It is also possible to find the same code listed in both Excludes1 and Excludes2 notes under a single code because, as explained above, a single code may represent multiple conditions.

For instance, J00 Acute nasopharyngitis [common cold] has an Excludes1 note for rhinitis NOS (J31.0) and an Excludes2 note for chronic rhinitis (J31.0). So it would be incorrect coding to file a claim reporting J00 for a cold and J31.0 for unspecified rhinitis. But it would be correct to report J00 for a cold and J31.0 for chronic rhinitis.

Because of gray areas like the exception and conflicting notes, practices should keep an eye out for issues with claims related to Excludes1 notes and follow payor instructions on following up. The Anthem post does not name these specific issues, but it does provide this guidance: “If you believe an Excludes1 note denial should be reviewed, please follow the normal claims dispute process and include medical records that support the usage of the diagnosis combination when submitting claims for consideration.”