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Do you know the difference between an Excludes1 note and an Excludes2 note?

Sometimes, it is simply impossible for a patient to have two diagnoses, and therefore two applicable codes, together at the same time. A tumor cannot be both malignant and benign. An exam cannot yield both normal and abnormal findings. One person cannot have both acute and chronic sinusitis at the same time.

That鈥檚 why Excludes1 notes are part of the ICD-10-CM Official Guidelines. Excludes1 notes exist to flag cases where two mutually exclusive codes should not be coded together.

To better understand the function of these notes, review these examples and tips for navigating Excludes1 notes.

See Sample Excludes1 Notes

The 10^th edition of the ICD-10-CM code set includes I51.9 (Heart disease, unspecified). The Excludes1 note for this code is:

• Any condition in I51.4-I51.9 due to hypertension (I11.-)
• Any condition in I51.4-I51.9 due to hypertension and chronic kidney disease (I13.-)
• I00-I09 (Heart disease specified as rheumatic)

This is because, by definition, heart disease cannot be unspecified if it is specified.

Let鈥檚 look at another example.

The C43- (Malignant melanoma of skin) ICD-10-CM code set has the following Excludes1 note: D03.- (Melanoma in situ). This is because it is not possible for a patient to simultaneously have stage 0 melanoma, also known as melanoma in situ, while also having advanced melanoma that has spread to other parts of the body. It is not possible for their disease to be in multiple stages at once.

Distinguish Excludes1 Notes from Excludes2 Notes

Whereas an Excludes1 note essentially translates to 鈥渄o not code here,鈥� an Excludes2 says 鈥渘ot included here,鈥� meaning that the excluded condition is not part of the condition represented in the code, but it is possible for the patient to have both conditions, and for coders to apply both codes when appropriate. Let鈥檚 use the Excludes2 note for L24- (Irritant contact dermatitis) as an example.

The Excludes2 note for the L24- ICD-10-CM code set is as follows:

• L23.- (Allergic contact dermatitis)
• L27.- (Dermatitis due to substances taken internally)
• H01.1- (Noninfectious dermatoses of eyelid)
• L22 (Diaper dermatitis)
• H60.5- (Acute noninfective otitis externa)
• L71.0 (Perioral dermatitis)
• L55-L59 (Radiation-related disorders of the skin and subcutaneous tissue)

It is acceptable to use any of the codes listed above alongside a code from the L24.- code set, when appropriate. For example, say a patient develops dermatitis around their eyes after using a new type of makeup. Assuming there is ample documentation in the patient鈥檚 medical record to support it, you would code both L24.3 (Irritant contact dermatitis due to cosmetics) and H01.1-.

Most of the time, you do not need to add the code(s) listed in an Excludes2 note. But sometimes, the Excludes2 list is a helpful reminder for coders to add any relevant additional codes to the claim.

For example, if a patient presents with superficial injuries to their arm, wrist, and hand, you may start with S50.- (Superficial injury of elbow and forearm). You would then notice that the Excludes2 note for this code set is S60.- (Superficial injury of wrist, hand and fingers). Since that code set is also applicable in this case, you would use the most specific applicable code from both code sets.

Know the Benefits of Excludes1 and Excludes2 Notes

Both Excludes1 and Excludes2 notes help enforce correct coding. Payers will deny claims that include mutually exclusive codes 鈥� that鈥檚 why it鈥檚 important for coders to be aware of Excludes1 notes for each code that they include.

To reduce denials, pay attention to the Excludes1 and Excludes2 notes for every ICD-10-CM code that you list on a claim. It is always best practice to use the most specific code available; often, Excludes1 errors occur when a coder combines a code for a specific diagnosis with a more generalized code for the same diagnosis.

If you receive a denial that you think is incorrect, double check the Excludes1 and Excludes 2 notes; if you still believe the denial is incorrect, provide supporting documentation to explain why it is correct to use the two codes together and follow the dispute process.

Recognize Rare Exceptions to Excludes1 Notes

There is one scenario that evades the rules of Excludes1 notes: If a patient has two or more unrelated conditions, you can code the secondary or tertiary condition with the primary diagnosis despite the Excludes1 note if the secondary condition(s) will impact the patient鈥檚 episode of care. The key here is that the conditions must be unrelated: The secondary/tertiary diagnoses must not typically be associated with the primary diagnosis.

The ICD-10-CM Official Guidelines uses a case of sleep-related teeth grinding as an example of an exception to the Excludes1 rule. The Excludes1 note for F45.8 (Other somatoform disorders) is G47.63 (Sleep related bruxism). In this example, the patient has unrelated psychogenic dysmenorrhea. In this instance, it is acceptable to code both F45.8 and G47.63 even though psychogenic dysmenorrhea is an inclusion term under F45.8 because the psychogenic dysmenorrhea and sleep-related teeth grinding are unrelated to each other.

Michelle Falci, BA, M Falci Communications LLC, Contributing Writer