Coding R78.81 with F11.10

zgb49

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I was told by an insurance company that as per CMS Guidelines ICD-10 code R78.81 and F11.10 cannot be billed together. I am having a hard time finding information on the reason why. Does anyone know why these two codes can't be billed together?
 

thomas7331

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They are probably referring to the Excludes1 note under section R78. However, as you probably know, Excludes1 does not mean the two cannot be billed together, but only that the conditions that listed in the excludes1 note are not to be coded using the R78 category. Clearly that is not the case with two codes you list, so I believe the insurance company is mistaken here.
 

sconnell08

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Yes, you are correct in that there is an Excludes 1 note under the code category R78 and rightly so, especially when it comes to mental or behavioral disorders with evidence of psychoactive substance use. If you search recent medical publications, one will find that bacteremia can often occur in those with substance abuse (e.g., opioids, cannabis, cocaine, etc.). Therefore, in order to capture these two codes, the provider would need to document that they are not related to one another and you would most likely need to submit that documentation. However, given the information provided, one would assume that they are related and cannot be coded together. I have included a case study regarding this matter below.

Opioid Dependent Malingerer with Self-Induced Sepsis

I hope that answers your question. If not, let me know and I'd be happy to provide you with more information. Have a great day!
 
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