Excledes 1 explanation needed for a physician

MSCALLIE79

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I am having trouble explaining the reason for excludes 1 rule to a physician for a patient that has strabismus (esotropia H50.011) and strabismic amblyopia (H53.031).
His response "Those are two related but separate diagnoses that require separate assessments and treatments. Many patients with strabismus do not have strabismic amblyopia, so the second diagnosis is a necessary addition that clearly adds more information. It's like a patient with hypertension and coronary disease. The hypertension might have caused the heart disease, but you still document and address the two problems separately. Can you please clarify the reasoning why I cannot document both of these diagnoses in the same patient?"

Can anyone give me a clinical explanation for these 2 codes?
 

mitchellde

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As you said those with strabismus do not necessarily have strabismic amblyopia , however the rest of that statement would be those with strabismic amblyopia have strabismus.. It would be like coding the diagnosis of strabismus twice which we do not do. it does not mean that you cannot use the same diagnosis for two procedures. exclude 1 means it cannot be coded separately because it is already inclusive.
 

thomas7331

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I agree, and would add that you can find a good official explanation for the excludes 1 notes for your provider in section 1 of the ICD-10 official guidelines. As stated there, the excludes note means simply 'not coded here' - of important note, it does not say 'do not document'. I'd let your provider know that the excludes 1 notes are just coding guidelines for how to classify and report diagnoses in ICD-10 - these are not instructions on how a provider should document these conditions. There really isn't a clinical reason for this - it's just how the language of this particular reporting system is structured. ICD-10 codes can never completely report every detail in a patient record, and are not designed to do that. So this should not affect the work that the provider does, and he or she should continue to document the record in the manner that most clinically accurately and completely reflects the patient's condition and treatment.
 
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jademound

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I would agree with Thomas. The excludes 1 notes are for coding; that means that when coding, you do not include both codes. However, that does not mean that they provider should not document both conditions. The coding aspect is separate from the documentation aspect. The provider should fully document the patient's condition; however, as a coder, you do need to follow the coding guidelines.
 
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