Claims editing update for ICD-10-CM Excludes1 notes

Beginning with dates of service on or after January 1, 2021, we will be implementing revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To help ensure the accurate processing of claims, use ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for member encounters. Please remember to code to the highest level of specificity. For example, if there is an indication at the Category level that a code can be billed with another range of codes, it is imperative to look for Excludes1 notes that may prohibit billing a specific code combination. w q

Visit this site for assistance in determining proper coding guidance.

 

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 billed with the code or code range listed above the Excludes1 note. These notes appear below the affected codes – if the note appears under the category (first three characters of a code), it applies to the entire series of codes within that category.  If the Excludes1 note appears beneath a specific code (3, 4, 5, 6 or 7 characters in length) then it applies only to that specific code. 

 

In ICD-10-CM, when a category includes an Excludes1 note, it outlines what codes should NOT be billed together.  Examples of this code scenario would include but are not limited to the following:

• Reporting Z01.419 with Z12.4
  • Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below it that includes Z12.4 (encounter for screening malignant neoplasm cervix)
• Reporting Z79.891 with F11.2X
  • Z79.891 (long-term use of opiates) has an Excludes1 note below it for F11.2X (opioid dependence)
• Reporting M54.2 with M50.XX
  • M54.2 (cervicalgia) has an Excludes1 note below it for M50.XX (cervicalgia due to intervertebral disc disorder)
• Reporting M54.5 with S39.012X and/or M54.4X
  • M54.5 (low back pain) has an Excludes1 note below it which includes: S93.012X (strain of muscle, fascia and tendon of lower back), M54.4X (low back pain) M51.2X (lumbago due to intervertebral disc disorder)
• Reporting J03.XX with J02.XX, J35.1, J36, J02.9
  • J03.- (acute tonsillitis) has an Excludes1 note below it which includes: J02.- (acute sore throat), J35.1 (hypertrophy of tonsils), J36 (peritonsillar abscess)
• Reporting N89 with R87.62X, D07.2, R87.623, N76.XX, N95.2, A59.00
  • N89 (other inflammatory disorders of the vagina) has an Excludes1 note below the category for: R87.62X (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), A59.00 (trichomonal leukorrhea)

 

Finally, if you believe an Excludes1 note denial is incorrect, please consult the ICD-10-CM codebook to verify appropriate use of the billed codes and provide supporting documentation through the normal dispute process as to why the billed diagnoses codes are appropriately used together.

 

896-0121-PN-NE