Claims editing update for ICD-10-CM Excludes 1 notes
Beginning with dates of service on or after April 1, 2021, Anthem will be implementing revised claims editing logic tied to Excludes 1 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 Excludes 1 notes that may prohibit billing a specific code combination.
For assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm
One of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 notes. An Excludes 1 note indicates that the excluded code identified in the note should not be billed with the code or code range listed above the Excludes 1 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 Excludes 1 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 Excludes 1 note, it outlines what codes should NOT be billed together. Examples of this code scenario would include bur are not limited to the following:
- Reporting Z01.419 with Z12.4
Z01.41X (encounter GYN exam w/out abnormal findings) has an Excludes 1 note below that includes Z12.4.
Z12.4 (encounter for screening malignant neoplasm cervix)
- Reporting Z79.891with F11.2X
Z79.891 (long-term use of Opiates) has an Excludes 1 note after it for F11.2X. F11.2X (Opioid dependence)
- Reporting M54.2 with M50.XX
M54.2 (Cervicalgia) has an Excludes 1 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 Excludes 1 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 Excludes 1 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 Excludes 1 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 Excludes 1 note denial is incorrect, please consult the ICD-10-CM code book 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.
April 2021 Anthem Provider News - Virginia