Temporary edit suspension for Excludes1 and Excludes2 notes

August 7, 2018

In March 2018, we began to communicate, through a series of articles, that claims received by Independence starting in June 2018 would be subjected to a new claim editing process during prepayment review. The new process specifically highlights the ICD-10 coding rules. Since the implementation of this new editing process, we have received a significant number of claims with billing errors relating to the Excludes1 and Excludes2 notes coding guidelines.

As a result, as of July 13, 2018, Independence has temporarily suspended these edits in order to give providers more time to make their billing systems compliant with the ICD-10 Excludes1 and Excludes2 notes billing rule. If you are a provider who submitted a high volume of claims with these errors, an Independence representative will contact you with your claim examples.

Coding Convention ? Excludes Notes

According to the ICD-10-CM Official Guidelines for Coding and Reporting, there are two types of excludes notes, Excludes1 and Excludes2. Each type has a different definition for use, but they are both similar in that they indicate that codes excluded from each other are independent of each other.

Excludes1

Excludes1 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 note 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 involving an Excludes1 note are related or not, request clarity from the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for ?sleep related teeth grinding (G47.63),? because ?teeth grinding? is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8. A patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other. It would be appropriate to report F45.8 and G47.63 together.

Excludes2

Excludes2 represents ?NOT INCLUDED HERE.? An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Common coding errors

The following chart contains common coding errors received by Independence:

Mutually exclusive combination per ICD-10 Excludes1 NotesDescription
Q66.51 ? M21.41 ? Congenital pes planus, right footFlat foot (pes planus) (acquired), right foot
K92.2 ? K29.70 ? Gastro intestinal hemorrhage, unspecifiedGastritis, unspecified, without bleeding
K51.00 ? K58.0 ? Ulcerative (chronic) pancolitis without complicationsIrritable bowel syndrome with diarrhea
K01.1 ? M26.34 ? Impacted teethVertical displacement of fully erupted tooth or teeth
I49.5 ? R00.1 ? Sick sinus syndromeBradycardia, unspecified
D61.818 ? D70.9 ? Other pancytopeniaNeutropenia, unspecified
Z01.419 ? Z12.4 ? Encounter for gynecological examination (general) (routine) without abnormal findingsEncounter for screening for malignant neoplasm of cervix
R06.02 ? J96.01 ? Shortness of breathAcute repository failure with hypoxia
K63.0 ? K57.80 ? Abscess of intestineDiverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
P29.3 ? Q25.0 ? Persistent fetal circulationPatent ductus arteriosus
K56.600 ? P76.0 ? Partial intestinal obstruction, unspecified as to causeMeconium plug syndrome

For more information

To learn more about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet? Plan Central. Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com.

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