Claims editing update for ICD-10-CM Excludes1 notes

Beginning with dates of service on or after December 1, 2021, Anthem Blue Cross and Blue Shield will implement revised claims editing logic tied to Excludes1 notes from ICD-10-CM 2020 coding guidelines. To 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.

 

If you need assistance in determining proper coding guidance, the following site should be helpful: https://www.cdc.gov/nchs/icd/icd10cm.htm.

 

What are Excludes1 notes?

One of the unique attributes of the ICD-10-CM 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.

 

Examples

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
  • 41X (encounter GYN exam w/out abnormal findings) has an Excludes1 note below that includes Z12.4 (encounter for screening malignant neoplasm cervix).
• Reporting Z79.891 with F11.2X
  • 891 (long-term use of opiates) has an Excludes1 note below it that includes F11.2X (opioid dependence).
• Reporting M54.2 with M50.XX
  • 2 (cervicalgia) has an Excludes1 note below it that includes M50.XX (cervicalgia due to intervertebral disc disorder).
• Reporting M54.5 with S39.012X and/or M54.4x and/or M51.2X
  • 5 (low back pain) has an Excludes1 note below it that includes:
    • S39012X (strain of muscle, fascia and tendon of lower back)
    • 4X (low back pain)
    • 2X (lumbago due to intervertebral disc disorder)
  • Reporting F32 with F30, F31, or F33
    • F32 (Major Depressive disorder, single episode) has an Excludes1 note below that includes:
      • F30 (manic episode)
      • F31 (bipolar disorder)
      • F33 (recurrent depressive disorder)
    • Reporting J03.XX with J02.XX, J35.1, J36, J02.9
      • - (Acute tonsillitis) has an Excludes1 note below it that includes:
        • - (acute sore throat)
        • 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 that includes:
          • 62X (abnormal results from vaginal cytological exam)
          • 2 (vaginal intraepithelial neoplasia)
          • 623 (HGSIL of vagina)
          • XX inflammation of the vagina)
          • 2 (senile [atrophic] vaginitis)
          • 00 (trichomonal leukorrhea)
        • Reporting F91 with Z72.81 or F60.2
          • F91 (conduct disorder) has an Excludes1 note below it that includes Z72.81 (antisocial behavior),
          • 2 (Antisocial personality)
        • Reporting O26.843 with Z03.74
          • 843 (uterine size-date discrepancy, third trimester) has an Excludes1 note below it that includes:
            • 74 (encounter for suspected problem with fetal growth ruled out)

 

Finally, if you believe an Excludes1 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 claim payment dispute process as to why the billed diagnoses codes are appropriately used together.

 

If you have questions about this communication or need assistance with any other item, call Provider Services at 855-558-1443 or contact your local Provider Experience Consultant.

 

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