ICD-10-CM Excludes 1 notations impact the bottom line

April 29th, 2019 / By Rebecca Caux-Harry

While reading AAPC’s Healthcare Business Monthly, April 2019, I came across an article about problem lists by Mary Wood and Michael Warner. The authors include an example of a poorly maintained problem list that contained both I10 Essential (primary) Hypertension, everyone’s favorite ICD-10 code, and R03.0 Elevated blood-pressure reading, without diagnosis of hypertension. The symptom probably preceded the diagnosis, but the problem list wasn’t updated afterward, leaving contradictory information on the list. This example got me thinking about ICD-9 compared to ICD-10, as well as the impact of EMRs on the quality of coding.

Back when I first started seeing problem lists at the beginning of an E&M note, the notes were dictated and transcribed and the list was recreated for each new visit.  Not so now that the industry is using EMRs with templates, check boxes and auto-populated fields (the problem list from the last visit, for example) regardless of whether or not the data has been reviewed. This is one of the reasons we have the phrase “the problem list is a problem.” The above example of I10 and R03.0 being coding on the same claim is a direct result of this practice. If everyone is too overwhelmed with administrative burden to review and update the problem list and resulting codes prior to submitting a claim, poor or false data is submitted. 

What does this have to do with Excludes 1 in ICD-10? Well, if you have been coding for a while, you know we didn’t have this concept in ICD-9-CM. There was nothing to stop us, other than logic, from submitting a claim with these two contradictory codes on it. Enter the concept of Excludes 1. These notations within the ICD-10-CM manual guide us to not code mutually exclusive medical conditions together. I like to think of Excludes 1 as the NCCI edits of the diagnosis world. But a modifier won’t bypass the Excludes 1 notation. Oddly, there isn’t any restriction—again, other than logic—of coding I10 and R03.0 together.

Until recently, I hadn’t heard of any payers denying claims with ICD-10 codes that can’t be coded together. But, it has started to happen. Having good tools to alert coders or providers about ICD-10 coding conflicts will be the key to avoiding costly denials and rework. For those of you still using coding books, a warning: Not all Excludes 1 notations are reciprocal. Looking up a single diagnosis code is not enough; you need to look up all of them to ensure you aren’t violating ICD-10 coding convention. You also need to be diligent about checking for Excludes 1 notations associated with each category. Electronic tools will speed the process of finding all notations associated with each diagnosis code. ICD-10 coding accuracy and compliance is becoming more important to the bottom line. Take the time to check your coding tools for appropriate alerts, ensure your books are current and educate all team members that are selecting diagnosis codes for claims. 

The Excludes 1 concept will not solve the problem with the problem list, however. That’s a horse of a different color.

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.