# Auditing when Excludes2 Note aplies to code Q825-Congenital non-neoplastic nevus



## KellyLR (Mar 8, 2019)

Hello Everyone!

Need a little help. I hate the Excludes2 Note in the Convention Coding Guidelines! But, I need some direction applying this convention. Should I let stand a coded Q825-Congenital non-neoplastic nevus and the coded D2211-Melanocytic nevi of right upper eyelid, including canthus (as this also describes with more specificity from the provider's documentation on the Newborn record) or should I remove the D2211 code since this condition falls under Q825?

Thanks to everyone for your help!


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## thomas7331 (Mar 8, 2019)

What exactly does the provider's documentation say?  It's a bit of a guessing game without being able to read the record.


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## KellyLR (Mar 8, 2019)

Hi Thomas,

Apologies for delay. 

The medical record documentation by provider states "Nevus simplex on right upper inner eyelid" The coder coded D22111-Melanocytic nevi of right upper eyelid, including canthus and G825-Congenital non-neoplastic nevus

In my opinion, provider did not document with specific detail to validate using code D22111

My intention is to drop D22111 and keep Q825


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## meghanhannus (Mar 8, 2019)

*Nevus Simplex is a capillary malformation*

KellyLR,

I agree with your diagnosis of Q82.5 only as a Nevus Simplex is a capillary malformation (_birthmark_).


M.Hannus, CPC, CPMA, CRC


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## thomas7331 (Mar 8, 2019)

The term 'simplex' in the ICD-10 alphabetical index has the instruction 'see condition' which leaves 'nevus' as the only choice for coding.  Nevus NOS codes under category D22, so I would code the D22.111 - though it may well be congenital, it is not documented as such.


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## meghanhannus (Mar 8, 2019)

*Nevus Simplex is a capillary malformation (birthmark)*



thomas7331 said:


> The term 'simplex' in the ICD-10 alphabetical index has the instruction 'see condition' which leaves 'nevus' as the only choice for coding.  Nevus NOS codes under category D22, so I would code the D22.111 - though it may well be congenital, it is not documented as such.



I believe the provider would not have to document congenital as the medical definition of a Nevus Simplex or Naevus flammeus nuchae, (_often called a stork bite_) is a congenital capillary malformation. It is a common type of birthmark i and is usually temporary. Using a NOS diagnosis would not be correct because the diagnosis is specified.


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## thomas7331 (Mar 8, 2019)

​


meghanhannus said:


> I believe the provider would not have to document congenital as the medical definition of a Nevus Simplex or Naevus flammeus nuchae, (_often called a stork bite_) is a congenital capillary malformation. It is a common type of birthmark i and is usually temporary. Using a NOS diagnosis would not be correct because the diagnosis is specified.



I don't disagree with you on the nature of this condition, however following the coding guidelines does not take you to the congenital diagnosis as it is documented here.  As a coding auditor, I would not penalize a coder for strictly following the guidelines in choosing this code.  From a coding quality perspective, it is better that a coder hold strictly to the guidelines rather than pulling information from outside sources because once you start allowing or requiring that, it becomes very difficult to know where to draw the line as to when it become a matter of making clinical interpretations that are outside of the scope.  

Either way, this is a bit of a technicality here - we're talking about semantics.   I would call this a 'variance' rather than an error - neither of the codes would substantially or materially alter or misrepresent the information in the record.


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## thomas7331 (Mar 9, 2019)

KellyLR said:


> Hello Everyone!
> 
> Need a little help. I hate the Excludes2 Note in the Convention Coding Guidelines! But, I need some direction applying this convention. Should I let stand a coded Q825-Congenital non-neoplastic nevus and the coded D2211-Melanocytic nevi of right upper eyelid, including canthus (as this also describes with more specificity from the provider's documentation on the Newborn record) or should I remove the D2211 code since this condition falls under Q825?
> 
> Thanks to everyone for your help!



It occurs to me that we did not really answer your original question here regarding the Excludes2 note.  The note indicates that the conditions listed under the heading there are to be coded with the different classification that is indicated, but that it is acceptable to code both if the patient has both conditions.  So based on the documentation you posted above, the provider has only indicated that this is a single condition, not two, so it should only be coded with single code, and the incorrect code (whichever you ultimately decide that is) should be removed.


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## KellyLR (Mar 9, 2019)

thomas7331 said:


> It occurs to me that we did not really answer your original question here regarding the Excludes2 note.  The note indicates that the conditions listed under the heading there are to be coded with the different classification that is indicated, but that it is acceptable to code both if the patient has both conditions.  So based on the documentation you posted above, the provider has only indicated that this is a single condition, not two, so it should only be coded with single code, and the incorrect code (whichever you ultimately decide that is) should be removed.



Thanks to all for this discussion. Let me re-quote what was documented in medical record.

_The medical record documentation by provider states "Nevus simplex on right upper inner eyelid" The coder coded D22111-Melanocytic nevi of right upper eyelid, including canthus and G825-Congenital non-neoplastic nevus

In my opinion, provider did not document with specific detail to validate using code D22111

My intention is to drop D22111 and keep Q825 _

To be able to validate coding the D22111, I would like to have read from provider that this condition included the canthus (where the two eyelids meet) but provider did not document this. There is not a suitable code in D22 series that says "without canthus" So I am of understanding that this condition always includes the canthus per Icd-10 classification. However, I looked at images online that this condition affects the eyelids and not always including the canthus.

I do not wish to banter this but just want to say, THANK YOU ALL for pitching in and helping me with a decision! 

What I decided to do, since the coder coded it, I will ding the record, keeping the congenital code (this was during newborn period, initial hospital stay) explain my rationale, and let the coder find the documentation support if it is there. I did not see a query but, I feel the provider could have documented it correctly to begin with and not use lay terminology. Because of the images I reviewed online I feel that a code without canthus would suffice using the two codes together with the Excludes2 note in play if indeed this condition did not involve the canthus. I do see where the provider described it as inner eyelid but what does that mean? At the corner(s)? Who knows, all I know is it left me wondering what was meant by inner eyelid to validate D221-

FYI been hitting these group of hospitals lately for documentation improvement and have rebutted several issues. My goal is to reduce queries and give coders solid documentation to code with.


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## thomas7331 (Mar 10, 2019)

KellyLR said:


> Thanks to all for this discussion. Let me re-quote what was documented in medical record.
> 
> _The medical record documentation by provider states "Nevus simplex on right upper inner eyelid" The coder coded D22111-Melanocytic nevi of right upper eyelid, including canthus and G825-Congenital non-neoplastic nevus
> 
> ...



I don't want to beat a dead horse either, but I think you're misunderstanding the classification a little bit here.  I do not take the '_including canthus_' indication in the code description to mean that the code can only be assigned if the lesion involves the canthus - rather that a lesion of the canthus is included in this code.  For comparison, a basal cell carcinoma of the skin of the leg would code to C44.71X which is 'basal cell carcinoma of lower limb, _including hip_' which does not mean that this is only for lesions that involve the hip, (then there would be no code for the lesion of just the leg?) but rather that hip lesions would be included in this code.  If that were the not the case, then we likewise would have no 'suitable' codes for a leg lesions unless the provider specified  that the hip was involved.  But ICD-10 is clearly set up to include lesions of the leg other than the hip in this code, as you can confirm in both the alphabetic index and the neoplasm table.  

Remember that the code is a classification, not a diagnosis.  I think of it like a shelf in a library - that shelf contains books about multiple related topics, and the code identifies that shelf - it's not meant to tell you everything that's in the book itself.  Also remember that the coding guidelines instruct us to start in the alphabetic index ("_To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, *first locate the term in the Alphabetic Index, and then verify the code in the Tabular List*. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List_.") The alphabetic index should drive you to the code.  As mentioned above, 'Nevus NOS' directs the coder to D22 and _Nevus --> Skin --> Eyelid _ takes us to D22.1-, so this is a correct coding for what is in the record.  There would be no need to query a provider for additional information or documentation improvement here because the record is sufficient for coding purposes (whether or not it is clinically sufficient is another question entirely).  

Again, don't mean to belabor this, but it's a great discussion point and I learn from these questions too.  Thanks and happy auditing!


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## KellyLR (Aug 27, 2020)

Hello All, 

I was able to track this claim and it was sent back to provider for clarification of "inner eyelid" My suspicions were right. This was not an external nevus rather under the eyelid ivolving the internal superior conjuctiva, but breeching to the external. Got paid with the Q code alone.


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