One of the many benefits of working for a nation-wide company is visibility into payer actions from coast to coast. Our many customers send us comments about payer actions and ask if we can help with some of the issues. This is an extremely valuable process as it helps us learn about your pain points. One such comment that came in recently really surprised me. I’ve been working in the healthcare industry for over 20 years and I thought I couldn’t be surprised anymore. What a silly thought!
Those of us who have been in professional coding for a while have seen the changes in the last several years in our coding realm. We were focused primarily on CPT coding, because the dollars and compliance risk were there. But everything coming from CMS recently is telling me that we’re moving away from fee-for-service toward value-based care and this move makes correct ICD-10 coding more important than ever. The comment, coming from the East Coast, was concerning a commercial payer that had started denying claims because of an Excludes 1 note associated with the submitted ICD-10 codes.
In ICD-9, we only had a single Excludes note associated with a given code. That note could mean either “these two things are mutually exclusive” or “code both things if the patient has both.” In ICD-10, however, these two definitions became two different Excludes notes. Excludes 1 is the mutually exclusive direction, meaning we shouldn’t/can’t code the two ICD-10 codes together. This is the important one. For the most part, we coders know this rule and are careful to follow it, but what about the providers?
The majority of professional services are coded by the providers. Most of those codes go directly to billing without coder review. We could argue whether this is ideal, but that’s a discussion for another time. We’ve been diligent about educating providers about selecting the correct E/M code and the most specific ICD-10 code(s) possible. But I’ve never talked to providers about proper ICD-10 coding convention.
That was an oversight on my part based on my experience with payers. I had never seen a denial of a claim based on a non-primary ICD-10 code in the primary position, nor a primary-only ICD-10 code in a non-primary position. And I certainly hadn’t seen a denial because of mutually exclusive ICD-10 codes reported on the same claim. Well, some East Coast coders can’t say that anymore.
Who knows if other commercial payers or government payers will soon follow. Even if they don’t, it would benefit all to start including proper ICD-10 coding convention, especially Excludes 1 and Excludes 2, as part of your education to anyone responsible for selecting ICD-10 codes to go on a claim.
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Photo courtesy of: 3M Inside Angle
Originally Published On: 3M Inside Angle
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