New Guidance on Excludes1 for ICD-10-CM Effective October 1, 2016

In October of 2015 there was new guidance on Excludes1 and the intention of the instructional note. Although the general ICD-10 instruction at that time was that an Excludes 1 note means you cannot code two conditions together, the National Center for Health Statistics posted an exception on their website. The NCHS is one of the 4 cooperating parties for ICD-10, and is responsible for posting the ICD-10 code book and guidelines.  The exception reads as follows:

“We have received several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. Answer: If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. For example, the Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and bipolar disorder. In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-). Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-.”

You can read the exception on their website, as well as download important ICD-10 documents at: http://www.cdc.gov/nchs/icd/icd10cm.htm

A clarification was made on the “Excludes1” annotation in the new 2017 ICD-10-CM Guidelines that became effective October 1, 2016.  The excerpt is below with changes in bold blue:

A. Conventions for the ICD-10-CM

12. Excludes Notes

  1. 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 is not clear whether the two conditions involved in an Excludes1 note are related or not, query the provider.

This is in support of the clarification made in 2015 that Excludes1 means that two conditions are not normally reported together, but in some circumstances (when they are not related), they may be coded together.

Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP is an AAPC-approved PMCC medical coding instructor, and ICD-10-CM trainer and the author of the AAPC CRC® curriculum. He has specialized in risk adjustment from the very beginnings of these models being utilized and has assisted large and small clients nationally. He has special interest in ethics, patient safety, disease management, and management and leadership of people. Brian is a veteran of Desert Storm, where he served on active duty with the US Air Force with a job specialty of Aeromedical Evacuation. He went into physician practice management and medical coding after an honorable discharge. He is the CEO of ionHealthcare®, LLC, a company that specializes in risk adjustment coding & support services. For additional inquiries contact ionHealthcare® at info@ionHealthcare.com.