Alert coders of Excludes1 conflicts to help you catch problems in problem lists and avoid costly denials and rework.
By Rebecca Caux-Harry, CPC
In April’s Healthcare Business Monthly (pages 56-57), in the article “Take the Problem Out of Problem Lists,” authors Mary Wood, CPC, CPC-I, and Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow, include an example of a poorly maintained problem list that contained both I10 Essential (primary) hypertension (everyone’s favorite ICD-10 code) and R03.0 Elevated blood-pressure reading, without diagnosis of hypertension. The symptom probably preceded the diagnosis, but the problem list wasn’t updated afterward, leaving contradictory information on the list. This example illustrates the ongoing importance of understanding ICD-10 compared to ICD-9, as well as the impact of electronic health records (EHRs) on the quality of coding.
How Problem Lists Evolved into Real Problems
Years ago, when problem lists began appearing at the beginning of an evaluation and management (E/M) note, the notes were dictated and transcribed, and the list was recreated for each new visit. Now the industry is using EHRs with templates, check boxes, and auto-populated fields (the problem list from the last visit, for example) regardless of whether the data has been reviewed.
In the above example, I10 and R03.0 being coded on the same claim is a problem caused by failure to review and update the problem list and coding prior to submitting the claim. The result is poor or false data captured in the EHR and insurance claim.
Enter Excludes1 in ICD-10
What do problem lists have to do with Excludes1 notes in ICD-10? Experienced coders know this concept didn’t exist in ICD-9-CM; there was nothing to stop coders (other than logic) from submitting a claim with two contradictory codes.
Enter the concept of Excludes1: These notations in the ICD-10-CM code book guide coders to not code mutually exclusive medical conditions together. Think of Excludes1 as the National Correct Coding Initiative edits of the diagnosis world — except a modifier won’t bypass the Excludes1 notation. Unfortunately, there isn’t any restriction (again, other than logic) that prevents coding I10 and R03.0 together.
Until recently, payers were not denying claims that included ICD-10 codes that shouldn’t be coded together, but that is changing, and denials are now starting to happen. Having good tools to alert coders or providers about ICD-10 coding conflicts will be the key to avoiding costly denials and rework.
Check Your Coding Tools and Be Diligent
For professional coding teams still using coding books, a warning: Not all Excludes1 notations are reciprocal. Looking up a single diagnosis code is not enough; you should look up all of the applicable codes to ensure you are not violating ICD-10 coding conventions. Be diligent about checking for Excludes1 notations associated with each category. Electronic tools will speed the process of finding all notations associated with each diagnosis code.
ICD-10 coding accuracy and compliance are becoming more important to the bottom line. Take the time to check coding tools for appropriate alerts; ensure your coding books are current; and educate all team members who select diagnosis codes for claims.
AAPC Knowledge Center. Caux-Harry, R. Time to Step Up ICD-10 Excludes Education for Providers.
About the Author
Rebecca Caux-Harry, BFA, CPC, is product specialist, revenue cycle at 3M Health Information Systems. She has worked in the physician coding and billing industry for over 20 years, specializing in professional coding compliance. Caux-Harry has served as a clinic liaison to the insurance industry and provided compliance auditing and education to both physicians and coders. Caux-Harry joined 3M/CodeRyte as the product specialist for cardiology and has served in several rolls for the ambulatory products. She is a member of the Colorado Springs, Colo., local chapter.