Diagnosis Coding Excludes 1 Codes

Question:

Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.

Answer:

Great news to hear you are reviewing your claims edit reports timely. But, no, do not do that. The “Excludes 1” is an ICD-10-CM coding guideline also known as a coding rule. Think of this like an NCCI edit; when CMS has an edit between 2 CPT codes, we do not change the documentation in the operative note. Rather, we report the most comprehensive of the 2 CPT codes. The “Excludes 1” guideline is a similar concept—we do not change the documentation; instead, we report the most comprehensive diagnosis code.