Wiki Excludes 1

[CaroleF01]

Is there a rule as to which code to choose when there is an Excludes 1 note? As a trend, it seems that we choose the code that is listed in the Excludes 1 listing (and not the code I am looking up) because it often tends to be the more specific. But there are some pretty ambiguous Excludes 1's out there and I can't always figure out which one to use. Hope this makes sense!

 

[sathiya]

An Excludes 1 note means that the two conditions listed cannot be reported together under any circumstances, because:

• They are mutually exclusive, OR
  • Example 1:
    F10.20 – Alcohol dependence, uncomplicated
    Excludes 1: F10.10 – Alcohol abuse, uncomplicated
    
    You cannot code both because a patient cannot be both dependent and only abusive at the same time.
    
    ➤ Choose the code that best reflects the severity/diagnosis based on documentation (e.g., dependence > abuse).
• One is inherently included in the other (i.e., one is a more specific form of the other).
  • Example 2:
    I10 – Essential hypertension
    Excludes 1: I15.- Secondary hypertension
    
    These are not exactly "opposites," but secondary hypertension is more specific (it includes the cause), while essential hypertension is a catch-all when no cause is identified.
    
    ➤ You code only the more specific one (I15.-) when the cause is known.

If both conditions are documented, you must choose the one that best reflects the patient’s actual diagnosis and do not code both.

 

[jkyles]

Hi there, please see the ICD-10-CM guidelines for Excludes1 notes, including exceptions https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf.

The information starts on p. 9.

 

[CaroleF01]

Hi there, please see the ICD-10-CM guidelines for Excludes1 notes, including exceptions https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf.

The information starts on p. 9.

Yep, I understand what the Excludes 1 means. I'm just wondering if people are finding that the code that is listed in the excludes note is the one that ends up being coded.

 

[TThivierge]

Carole
Most healthcare billing & coding programs will edit to tell medical coder if Excluses 1 Rule is being violated .Thus to remove one of dx codes before bill it. If a choice between R dx code and definitive dx. I d use the definitive dx code. R dx code just symptoms. As example diarrhea R19.7 vs K59.1 or pain R52 vs M25 or M79 in selecting body area with the pain. You can use 2 dx codes in using the Exludes2 rules if documentation supports it.
I hope this is helpful
Lady T