Wiki Excludes 1 Clarification

[pswotton]

Can anyone clear up a question I have on an Excludes 1 note for K92.2?

But I’m saying that this would not INCLUDE Gastric ulcer, unspecified as acute or chronic, WITHOUT hemorrhage or perforation – K25.9. Can anyone offer clarification?

 

[mitchellde]

It does not mean it is included it means they cannot be coded together for one reason or the other. I may not be understanding your question. Can you clarify?

 

[pswotton]

It does not mean it is included it means they cannot be coded together for one reason or the other. I may not be understanding your question. Can you clarify?

Thanks for your response. My Payer is indicating that when coding K92.2 as the medical necessity for procedure, coding the bleeding cause, in this case K25.4, not allowed.

 

[pswotton]

Thanks for your response. My Payer is indicating that when coding K92.2 as the medical necessity for procedure, coding the bleeding cause, in this case K25.4, not allowed.

My question is based on the attachment i icluded, would that also exclude a non bleeding ulcer as that would also be coded as K25.x

 

[mitchellde]

If you have a confirmed non bleeding gastric ulcer then do you also have confirmation of GI bleeding from some other source? The excludes note is there to remind you that if you have unspecified GI bleeding but you know you have a gastric ulcer that is without bleeding k25.9 then can the GI bleed really be unspecified.
If you can prove that you have clear evidence of both yet still have no idea as to the source of the GIbleed then there is an exception in the guidelines for the excludes 1 provision that does allow you to code for both, you will of course have to appeal it using the guideline as your rationale plus the evidence that both do in fact exist one without the other.
Then K25.4 is again gastric ulcer with hemorrhage, which is more specific, does your documentation show gastric ulcer bleeding and GI bleeding from some other yet unidentified source. k92.2 is unspecified and once you use a more specific code you have nullified the idea that it is unspecified.