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Excludes notes get a makeover in ICD-10

Excludes notes in ICD-10 will have a slightly different look.

Currently in ICD-9, there are simply excludes notes listed below codes in italic font. In ICD-10, there are two types of exclude notes:

• Excludes1: 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 reported with the code above the Excludes1 note. An Excludes1 is used to indicate when two conditions cannot occur together, such as a congenital form and an acquired form of the same condition.
• Excludes2: A type 2 Excludes note is used to indicate ”not included here.” An Excludes2 note means that the condition excluded is not part of the condition under which it is listed, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to report both the code and the excluded code together.

Consider the following ICD-10 code:

F11.2 Opioid dependence

Excludes1: opioid abuse (F11.1x) opioid use, unspecified (F11.9x)

Excludes2: opioid poisoning (T40.0x-T40.2x)

Understand excludes notes in ICD-10

ICD-10 will bring a lot of welcome changes and correct many of the issues and shortcomings with ICD-9. One particular source of confusion with ICD-9 relates to the excludes notes. In ICD-9, the excludes notes can mean two things:

1. Do not code both of these codes together under any circumstances (e.g., a non-obstetrics code such as 629.81 [habitual aborter without current pregnancy] with an obstetrics code such as 646.33 [habitual aborter, antepartum condition], or a component of combination code 785.4 [gangrene] with combination code 440.24 [atherosclerosis of the extremities with gangrene]).

2. A particular condition is not classified to a specific code, but the coder is directed to another code or code category for the proper code for that particular condition; however, if both conditions occur, coders should assign the code that specifies both conditions. For example, code 787.9X (other digestive system symptoms) excludes gastrointestinal (GI) hemorrhage (code 578.x); however when both GI hemorrhage and diarrhea are present, then the coder can report both codes. An additional example would be when certain neurological symptoms classifiable to the 781 code category are present but they are not due to depression (code 311), the coder can code the neurological symptoms along with 311 despite the excludes note because both conditions are present.

This is very confusing concept in ICD-9 that will not be present in ICD-10.

In ICD-10, you will find the following:

• An excludes 1 note: meaning that the two codes are never assigned together
• An excludes 2 note: meaning simply that a different code should be assigned for that specific condition

I currently use ICD-10 to resolve personal coding questions of this nature when there is no other official guidance available. For example, I was trying to determine whether or not I can code pulmonary hypertension along with essential hypertension, which has been a controversial coding question for a long time. To make up my mind as to how I was going to treat the excludes note, I checked the ICD-10 codes for pulmonary hypertension, and the type of excludes note there is an excludes 1 note. So I used that to help me decide that I will only report code 416.0 or code 401.9, but I will not report both codes together.

If you’re not ready to dive in, start by getting your feet wet

We’ve read the words of caution and heard the urgency of the message: Don’t put off planning for ICD-10. And while there is no one-size-fits-all plan for implementation, there is one tip that everyone should bear in mind: It’s too early for coder training in ICD-10. Think about how well people retain information over time. Can you remember all of the coding guidance in Coding Clinic from six months ago? Can you remember the top 10 tips you learned at your last in-service training? Now imagine trying to remember all the knowledge you might gain in a week’s training four years from this point.

So what should coders be doing right now? Look at the basic coding conventions and the most obvious differences involved with the new coding system. For example, start with small nuggets of information and build on that slowly. Do you know what an Excludes 1 or an Excludes 2 note indicates?

Excludes1: Denotes “not coded here,” meaning coders should never report the excluded code at the same time as the code above the excludes1 note (e.g., the congenital form versus an acquired form of the same condition).

Excludes2: Denotes “not included here,” meaning that the condition excluded is not part of the condition represented by the code even though a patient may have both conditions at the same time. When an excludes2 note appears under a code, coders can report both codes together, when appropriate.

That wasn’t so bad was it? So for the coding side of this transition, start now but start small.