Excludes1 Rules (ICD-10)

We’ve updated our system to account for “Excludes1” rules in coding sessions. “Excludes1” means certain codes cannot be used together according to ICD-10 standards. If this is the case, you’ll see a warning message. Please choose the most relevant code.

What Excludes1 is

It means “Not Coded Here”. An Excludes1 note indicates that the code excluded should never be used at the same time as another code specifically indicated in the ICD-10 Coding guidelines. An Excludes1 is used when two conditions cannot occur together (i.e. mutually exclusive). 

If there is one rule that reigns over all of the ICD-10 coding rules, it’s this: Always—always—code to the most specific diagnosis code possible. To this end, you should never code a non-specific diagnosis with a specific diagnosis for the same problem. Otherwise, you will likely incur an Excludes1 edit, which will inevitably result in a claims denial.

Who decides on Excludes1

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) as part of the Department of Health and Human Services provide the guidelines for coding and reporting using ICD-10. 

Specific Conventions within ICD-10 are reviewed regularly for clinical appropriateness. 

Why this change was made

Payers have implemented revised claims editing logic tied to Excludes 1 notes from ICD-10 coding guidelines. Payers are “catching” these errors and we’ll be seeing more denials. To help ensure the accurate processing of claims, all claims should follow ICD-10 coding guidelines, thus the Excludes1 implementation.

The Excludes1 notes are not new, but they are being newly enforced. As payers update both their policies and their claims processing software, we’ll see more payers citing diagnosis exclusivity  (i.e. Excludes1 rule violation) for claim denials.

Insurance companies may or may not “catch” this error during initial claims processing. If they catch the error, they will deny the claim. If they don’t catch the error, they might never “reverse the decision” however, these claims are at risk for review– sometimes years after the date of service. 

Previous claims denied for Excludes1

If you have had denied claims as a result of Excludes1, we may reach out to and ask which diagnosis, of the mutually exclusive codes, you would like to use and resubmit your claims. Ideally, with the Excludes 1 rules in place we will prevent discrepancies rather than correct them.

Determining the appropriate diagnosis

The Excludes1 rules are not changing a code.  These rules require the elimination of a duplicate (mutually exclusive) code.

Please always remember to choose the code with the highest level of specificity for the particular date of service.

Benefits of coding according to the ICD-10 rules

Using the ICD-10 enables greater specificity in identifying mental health conditions. It also provides better data for measuring and tracking mental health care utilization and the quality of patient care.

This means that:

• You'll have fewer denials.
• As you work within the ICD-10 rules, your sessions are billed “cleaner” and there will be fewer requests for notes or additional information from the insurance companies.