Podiatry Coding & Billing Alert

Question: I am still confused by the Excludes1 and Excludes2 instructions in ICD-10-CM. Can you clarify the difference between them?

New Hampshire Subscriber

Answer: Excludes1 and Excludes2 instructions sound like they are similar notes. In fact, they have completely different functions in diagnosis coding.

ICD-10-CM guideline A.12.a. explains that ICD-10-CM regards an Excludes1 note as a “pure exclusion note.” The note means you cannot code the two conditions together because, medically, they cannot exist together and are generally mutually exclusive. To drive that point home, the guideline adds the words “NOT CODED HERE!” in capital letters and with an exclamation point.

So, when a provider documents two such diagnoses, you should exclusively report the code included in the Excludes1 parenthetical note per American Hospital Association (AHA) Coding Clinic (Q4, 2018) guidelines.

Note this exception: You can code Excludes1 codes together “when the two conditions are unrelated to each other,” according to the guideline. So, even though all the M25.5- (Pain in joint) codes are listed as Excludes1 codes for R52 (Pain, unspecified), you could code M25.57 (Pain in ankle and joints of foot) along with R52, for example, if your provider documents a patient has generalized pain in addition to foot or ankle pain and if the documentation shows that the generalized pain is not a result of the joint pain. In such cases, you would be correct in overriding the Excludes1 note and recording both conditions with the two codes.

An Excludes2 note, on the other hand, means a specific condition is “not included here.” In other words, a condition identified by an Excludes2 note is medically related to the main condition but can occur independently of that condition. It is separately reportable under a different ICD-10-CM code and not included under the ICD-10-CM code under which the Excludes2 note appears.

Coding alert 1: Never assume that Excludes notes are reciprocal. ICD-10-CM exclusions do not necessarily work both ways. For example, there is no corresponding note for the M25.5- codes that makes R52 an Excludes1 code for the joint pain codes.

Coding alert 2: Be sure to look to the instructions under each level in a code group, such as the Excludes2 note example above, as well as the ones that may accompany the specific code itself, to find all the Excludes notes that apply to a specific code. For instance, Excludes notes at the three-character level apply to all codes in that family, including any five-character codes in the family that have additional Excludes notes under them.