Home Health Coding and OASIS Expert

As ICD-10 codes begin to be put to practical use, some flaws with the shiny new code set are bound to arise. One such issue that’s been drawing attention is the definition of what “Excludes1” means.

The ICD-10-CM Official Guidelines for Coding and Reporting advise “A type 1 Excludes note 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.”

On the other hand, “A type 2 Excludes note 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.”

New way: In response to “several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another,” the Centers for Disease Control released the following updated guidance.

“If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note.”

For example: The Excludes1 note at code range R40-R46 (Symptoms and signs involving cognition, perception, emotional state and behavior) advises coders that symptoms and signs constituting part of a pattern of mental disorder reportable with a code from the F01-F99 (Mental, behavioral and neurodevelopmental disorders) code range cannot be assigned with R40-R46 codes. “However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and bipolar disorder,” the CDC says in the new guidance.

Another example: You’ll find an Excludes1 note for traumatic intracranial hemorrhage (S06.-) at code range I60-I69 (Cerebrovascular Diseases). “Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage,” the CDC advises. “However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-.”

“I’ve been teaching ‘Excludes1: choose one,’ ‘Excludes2: have both, code both,’” says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas. “I will have to modify that a bit. I now teach an ‘Excludes 1.5.’ Even when there is an Excludes 1 note, you may code both, if the two conditions are not related.”

Note: Read the CDC guidance here: www.cdc.gov/nchs/data/icd/Interim_Coding_advice_on_Excludes_1_note.pdf.