In March 2018, we began to communicate, through a series of articles, that claims received by AmeriHealth starting in June 2018 would be subjected to a new claim editing process during prepayment review. The new process specifically highlights the ICD-10 coding rules. Since the implementation of this new editing process, we have received a significant number of claims with billing errors relating to the Excludes1 and Excludes2 notes coding guidelines.
As a result, as of July 13, 2018, AmeriHealth has temporarily suspended these edits in order to give providers more time to make their billing systems compliant with the ICD-10 Excludes1 and Excludes2 notes billing rule. If you are a provider who submitted a high volume of claims with these errors, an AmeriHealth representative will contact you with your claim examples.
Coding Convention ? Excludes Notes
According to the ICD-10-CM Official Guidelines for Coding and Reporting, there are two types of excludes notes, Excludes1 and Excludes2. Each type has a different definition for use, but they are both similar in that they indicate that codes excluded from each other are independent of each other.
Excludes1
Excludes1 is a pure excludes note. It means ?NOT CODED HERE.? An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, request clarity from the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for ?sleep related teeth grinding (G47.63),? because ?teeth grinding? is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8. A patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other. It would be appropriate to report F45.8 and G47.63 together.
Excludes2
Excludes2 represents ?NOT INCLUDED HERE.? An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
Common coding errors
The following chart contains common coding errors received by AmeriHealth:
| Mutually exclusive combination per ICD-10 Excludes1 Notes | Description |
|---|
| Q66.51 ? M21.41 ? Congenital pes planus, right foot | Flat foot (pes planus) (acquired), right foot |
| K92.2 ? K29.70 ? Gastro intestinal hemorrhage, unspecified | Gastritis, unspecified, without bleeding |
| K51.00 ? K58.0 ? Ulcerative (chronic) pancolitis without complications | Irritable bowel syndrome with diarrhea |
| K01.1 ? M26.34 ? Impacted teeth | Vertical displacement of fully erupted tooth or teeth |
| I49.5 ? R00.1 ? Sick sinus syndrome | Bradycardia, unspecified |
| D61.818 ? D70.9 ? Other pancytopenia | Neutropenia, unspecified |
| Z01.419 ? Z12.4 ? Encounter for gynecological examination (general) (routine) without abnormal findings | Encounter for screening for malignant neoplasm of cervix |
| R06.02 ? J96.01 ? Shortness of breath | Acute repository failure with hypoxia |
| K63.0 ? K57.80 ? Abscess of intestine | Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding |
| P29.3 ? Q25.0 ? Persistent fetal circulation | Patent ductus arteriosus |
| K56.600 ? P76.0 ? Partial intestinal obstruction, unspecified as to cause | Meconium plug syndrome |
For more information
To learn more about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on AmeriHealth NaviNet? Plan Central. Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email to ahclaimeditquestions@amerihealth.com.
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