Your Secret Decoder for ICD-10-CM Notes Has Arrived!

Thu, Apr 18, 2019 --

ICD-10, Skill Sharpener

I’ve been working with ICD-10-CM notes recently, like Excludes1 and “code first.” One thing coders have to know about those notes is that they come with qualifiers. Let’s look at some of the not-so-obvious meanings of these ICD-10-CM notes.

Excludes1 Means “NOT CODED HERE!” Unless …

ICD-10-CM Excludes1 notes originally came with the explanation that you should never report the excluded code at the same time as the code above the note. The idea was that the two conditions in the two codes could never occur together. But life and coding aren’t always that simple.

In practice, coders found that in some cases when an excluded code covered many conditions, not all conditions should be excluded from reporting with another code.

That’s a confusing mouthful, but this example from the ICD-10-CM Official Guidelines (section I.A.12.a) should help. Start by reviewing the Tabular entry for F45.8:

F45.8 (Other somatoform disorders)

Psychogenic dysmenorrhea

Psychogenic dysphagia, including ‘globus hystericus’

Psychogenic pruritus

Psychogenic torticollis

Somatoform autonomic dysfunction

Teeth grinding

Excludes1: sleep related teeth grinding (G47.63).

As the Official Guidelines point out, F45.8 has an Excludes1 note for G47.63 (Sleep related bruxism) because teeth grinding is included under F45.8. Similarly, G47.63 has an Excludes1 note for “psychogenic bruxism (F45.8).” So you should choose only one of those codes (F45.8 or G47.63) for teeth grinding. But what if the patient has sleep related bruxism (G47.63) and psychogenic dysmenorrhea, which is included under F45.8. “In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together,” the Official Guidelines state.

Secret code: Excludes1 means “NOT CODED HERE!” unless you have a rare case where the two conditions are unrelated to each other.

Follow Code First and Use Additional Code Notes If …

If ICD-10-CM “code first” and “use additional code” notes make you fear long hours of convincing providers to add something to the documentation, you’ll be relieved to know the Official Guidelines offer some leeway.

Section I.B.7, “Multiple coding for a single condition,” includes the important words “if known.” Here’s the wording: “‘use additional code’ indicates that a secondary code should be added, if known … When there is a ‘code first’ note and an underlying condition is present, the underlying condition should be sequenced first, if known.”

Secret code: Add codes according to the code first and use additional code notes if the underlying condition or the condition related to the secondary code is known. That means there may be cases where you’ll end up reporting a single code despite it having a code first or use additional code note because it is the nature of the individual case.

Bonus tip: If you’re dealing with etiology/manifestation codes with code first and use additional code notes, be sure you follow the guidelines for etiology/manifestation coding.

But Here’s What Isn’t a Secret

Use the exceptions provided for Excludes1 and code first/use additional code notes as ICD-10-CM intends them. Be sure the documentation, the rules, the specifics of the case, and even common sense support your choice to report two excluded codes together or to report only a single code in the presence of a code first or use additional code note.

Also keep in mind that what we’re talking about here are Official Guidelines, not rules about coverage or payer policy. For instance, a payer may have a policy that indicates only a specific combination of ICD-10-CM codes will support medical necessity and reimbursement for a particular service.

What About You?

Do you apply these ICD-10-CM exceptions? What has your experience been?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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