May 16, 2019
The upcoming Inappropriate Diagnosis Combination edit, which is based on the EXCLUDES1 Notes in the ICD-10 CM Diagnosis Codebook, will be applied to Professional Claims later this fall. These edits are currently applied to Outpatient Hospital claims and will be expanding to Professional claims. The edit will enforce the ICD-10 CM EXCLUDES 1 correct coding guideline as established in the ICD-10 CM Diagnosis codebook in the Official Guidelines for Coding and Reporting:
Excludes1
A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it isn’t clear whether the two conditions involving an Excludes1 note are related or not, ask the provider (ICD-10 CM Official Guidelines for Coding and Reporting FY 2019).
For example, ICD-10-CM code S60.371A (other superficial bite of right thumb, initial encounter) should never be reported with the code categories S61.05- or S61.15- (open bite of the thumb). In this example, you would not assign code S60.371A along with S61.051A (open bite of right thumb without damage to nail, initial encounter) at the same time. Both codes have an EXCLUDES1 note for the other code. The coder would only assign one code to identify the most severe description (open) of the wound.
These EXCLUDES1 notes can be found throughout the ICD-10 CM codebook, either at the beginning of a code block which pertains to all codes in that block or additionally on the specific code itself. It indicates when two condition cannot occur together or are mutually exclusive (i.e. Not coded here). The excluded code identified in the EXCLUDES 1 note shouldn’t be used at the same time as the code or code range listed above the EXCLUDES 1 note.
This edit isn’t a denial for medical necessity or invalid codes but an edit which enforces correct coding guidelines as established by ICD-10 CM official coding guidelines.
By being aware of this upcoming edit and the ICD-10 CM Coding Guidelines for EXCLUDES1 notes, your claims will be reimbursed without any edits or delays. More information will be available when the edit goes live.