Excludes 1 diagnosis codes

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smihm

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We have a Medicare Advantage plan that has started denying claims for the reason of exclude 1- I understand the concept of excludes 1 and excludes 2

What is a happening we have an Office visit billed with a dx code and an office lab with a separate dx , Because the services were performed together they are on the same claim-


Is this a valid denial?

I could see if the 2 codes were on the same service but they are not -wanted to see if anyone else has come across this issue
Thanks
 
Thanks Debra

Here is one but - not the best
Pt had on Office visit that was billed with dx code N95.1( Menopausal and Female Climacteric states)
N95.1 shows excludes 1- Z78.0 Asymptomatic menopausal state

On the same day with us she also had labs - we have a lab so we bill those on a separate claim The labs were billed with Z78.0 which has excludes 2- N95.1
The lab charges are being denied
I'm not 100% why the office visit was billed with N95.1 and the labs with z78.0
 
The N code says the patient is symptomatic and the Z code says she is not. This is why there is an excludes 1 note, the patient cannot be both symptomatic and asymptomatic at the same encounter.
 
Question similar to this scenario

Pt is being seen for a prescription refill. She is on hormone replacement therapy for menopause. Documentation states pt is not experiencing any symptoms related to her menopause. Coder coded N95.1 due to that being her diagnosis at a previous visit when she was started on HRT, I looked at the previous note and the pt was experiencing symptoms at that time. I’m torn between using Z98.0 (asymptomatic menopause) or Z76.0 (encounter for repeat prescription). But I’m sure N95.1 isn’t right because it instructs you to use additional code for symptoms. I looked everywhere for documentation regarding this scenario and I can’t find anything.
 
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