Reminder: Enhanced claim edits to support correct coding principles and important information about ICD-10-CM Excludes Notes

July 24, 2020

As previously communicated in a Partners in Health UpdateSM article, claims received by Independence on or after June 10, 2018, are subject to a claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles, including:

  • Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
  • CMS HCPCS LEVEL II Manual coding guidelines
  • ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed, and additional claim edits will be implemented as applicable.

Self-funded groups have the option to opt out of the enhanced claim edits; therefore, your outcomes may vary by plan.

Excludes Notes edits

The ICD-10-CM Official Guidelines for Coding and Reporting includes 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. For more information and the specific definition of each type of note, please see the previous Partners in Health UpdateSM article, ICD-10 in Action: Coding guidelines and conventions – Excludes1 and Excludes2 notes.  

Independence reinstated a portion of the Excludes Notes edits for claims received on or after October 30, 2018. As we continue to align with industry standards, additional ICD-10-CM Excludes Notes edits will be applied and claims that are not billed in compliance with the ICD-10-CM Excludes1 and Excludes2 notes billing rules will be rejected. If you have been submitting claims based on the ICD-10-CM industry standard coding guidelines as instructed in our various enhanced claim editor communications, you will not see any impacts. However, if your claims submissions have not been in compliance with these billing rules, please be advised that you may see an increase in rejections and/or claim denials.

You can identify an Excludes Notes billing error on your Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility) when the line is rejected with the reason code E8038. The below chart contains common Excludes Notes coding errors still being received by Independence:


Examples of codes that represent conditions that are independent of each other and should not be reported together.

Diagnosis 1

Diagnosis 2

A41.9

Sepsis, unspecified organism

R78.81

Bacteremia

I20.0

Unstable angina

I25.10

Atherosclerotic heart disease of native coronary artery without angina pectoris

Z01.812

Encounter for preprocedural laboratory examination

Z32.01

Encounter for pregnancy test, result positive

K52.9

Noninfective gastroenteritis and colitis, unspecified

R19.7

Diarrhea, unspecified

R06.02

Shortness of breath

J96.01

Acute respiratory failure with hypoxia

R12

Heartburn

R10.13

Epigastric pain

R94.31

Abnormal electrocardiogram [ECG] [EKG]

I45.81

Long QT syndrome

R55

Syncope and collapse

I95.1

Orthostatic hypotension

K92.2

Gastrointestinal hemorrhage, unspecified

K57.30

Diverticulosis of large intestine without perforation or abscess without bleeding

I96

Gangrene, not elsewhere classified

I73.9

Peripheral vascular disease, unspecified

Resources

For additional resources on our enhanced claim editing process, please review the information below:

  • Claim edit enhancements: Frequently asked questions (FAQ). The FAQ includes additional information on our claim editing process as well as rules specific to:
    • durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers
    • injectable drugs and biological agents
    • Medicare Advantage
    • professional reporting of hospital observation care

Learn more

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

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