Payer edits referencing ICD-10-CM guidelines such as “Excludes 1” are on the rise.
When billing for an evaluation/management (E/M) visit, a patient has a left nonobstructed kidney stone (N20.0) and a right hydronephrosis ureteral stone (N13.2). In International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) under N20, it shows EXCLUDED 1: that with hydronephrosis (N13.2). Can I bill N20.0 and N13.2 on the same Current Procedural Terminology line (E/M line)? I have run into denied claims in the past, and I am not sure if I should bill only 1 ICD-10-CM or 2.
We are seeing an increase in payer edits that are referencing ICD-10-CM guidelines such as “Excludes 1” notes. As you mentioned, code N20.
includes the note:
• nephrocalcinosis (E83.5)
• that with hydronephrosis (N13.2)”
The note applies to all N20 codes, including N20.0, N20.1, and N20.2. The ICD-10-CM guidelines state that if code(s) notes include an Excludes 1 list, the ICD-10-CM codes listed under the note should not be reported in conjunction with the codes for which the note is listed. Interestingly, if you look under code N13.2, you will not see a reciprocal reference. In short, it is not correct coding to list code N20.0 and N13.2 for the same patient encounter.
It is correct coding to list a single diagnosis if the code accurately describes the patient’s condition. Therefore, you should not receive a denial if only 1 ICD-10-CM code is listed for the claim. If the patient has other conditions that are not listed in the notes as “Excludes 1” or “Includes codes,” it is appropriate to list more than 1 ICD-10-CM code, with few exceptions.
Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.
Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.