Claim editing update for Excludes1 notes

Beginning with claims processed on and after September 28, 2019, we will be implementing revised claims edit logic tied to Excludes1 notes from ICD-10 coding guidelines.  We recognize that the editing tied to Excludes1 notations found in ICD-10-CM, which was implemented in March 2019, contained some conflicts between Excludes1 and Excludes2 notes which caused a need for claims to be re-adjudicated. We have taken steps to modify the logic and remove such conflicts.

 

To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for patient encounters. ICD-10-CM has two types of excludes notes; each type has a different definition for use but they are similar since they indicate that codes excluded from each other are independent of each other. One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes1 notes. An Excludes1 note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes1 note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, it applies to all codes in the section.

 

Remember to review diagnosis code(s) for any Excludes1 notes prior to submitting your claims to help ensure proper adjudication of your claims.

 

Some examples of Excludes1 scenarios in ICD-10-CM, where both diagnosis codes should not be billed together include:

• Reporting both M54.2 (cervicalgia) with M50.XX (cervicalgia due to intervertebral disc disorder)

           - M54.2 has an Excludes1 note for M50.XX

• Reporting both M54.5 (low back pain) with S39.012X (strain of muscle, fascia and tendon of lower back)

           -M54.5 has an Excludes1 note for S93.012X

• Reporting both M54.5 (low back pain) with M54.4X (lumbago with sciatica)

           -M54.5 has an Excludes1 note for M54.4X

• Reporting J03.XX (acute tonsillitis) with J02.XX (acute sore throat), J02.0 (streptococcal sore throat), J02.9 (sore throat NOS), J35.1  (hypertrophy of tonsils) or J36 (peritonsillar abscess)

           -J03.XX has an Excludes1 note for J02.XX, J02.0, J02.9, J35.1
            and J36  

• Reporting N89 (other inflammatory disorders of the vagina) with R87.62 (abnormal results from vaginal cytological exam), D07.2 (vaginal intraepithelial neoplasia), R87.623 (HGSIL of vagina), N76.XX (inflammation of the vagina), N95.2 (senile [atrophic] vaginitis) or A59.00 (trichomonal leukorrhea)
  •  N89 has an Excludes1 note for R87.62, D07.2,            R87.623,N76.XX, N95.2, D07.2 and A59.00

 

Finally, 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.