Wiki Excludes1 edit for diagnosis codes Z11.3 and Z30.09

[klmcginnis]

Hello,

We are experiencing denials from the Georgia CMO Medicaid plans when Z11.3 and Z30.09 are billed together. After following up, the plans provided the explanation below:

“The billed service (99211) was denied because the associated diagnosis codes, Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission) and Z30.09 (Encounter for other general counseling and advice on contraception), should not be reported together.​

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Here is the CMS link showing excludes1 edits still apply for 2025:​

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ICD-10-CM Guidelines FY25 October 1 2024​

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According to the ICD-10-CM Official Guidelines for Coding and Reporting: "An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note." This means the two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.​

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The code Z11.3 does have an Excludes 1 Note: Examinations related to pregnancy and reproduction (Z30-Z36, Z39.-), which means any code between Z30 and Z36. Since Z30.09 falls within this range, the edit fired as intended. For additional information, you may also reference Encoder and consult the ICD-10 manual for proper coding guidelines.”​

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This issue has only recently started occurring, despite the ICD reference they cite having been in the manual for several years.

My question is:

• Is anyone else experiencing similar denials?
• Are there any known exceptions or guidance that supports billing these two codes together?

I’d appreciate any insight or shared experience from others on this.

Thank you,
Kim

 

[Cmama12]

Hello,

We are experiencing denials from the Georgia CMO Medicaid plans when Z11.3 and Z30.09 are billed together. After following up, the plans provided the explanation below:

“The billed service (99211) was denied because the associated diagnosis codes, Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission) and Z30.09 (Encounter for other general counseling and advice on contraception), should not be reported together.​

​

View attachment 8054​

​

Here is the CMS link showing excludes1 edits still apply for 2025:​

​

ICD-10-CM Guidelines FY25 October 1 2024​

​

According to the ICD-10-CM Official Guidelines for Coding and Reporting: "An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note." This means the two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.​

​

The code Z11.3 does have an Excludes 1 Note: Examinations related to pregnancy and reproduction (Z30-Z36, Z39.-), which means any code between Z30 and Z36. Since Z30.09 falls within this range, the edit fired as intended. For additional information, you may also reference Encoder and consult the ICD-10 manual for proper coding guidelines.”​

​

This issue has only recently started occurring, despite the ICD reference they cite having been in the manual for several years.

My question is:

• Is anyone else experiencing similar denials?
• Are there any known exceptions or guidance that supports billing these two codes together?

I’d appreciate any insight or shared experience from others on this.

Thank you,
Kim

Hi Kim, well let me ask why you want to bill them together? While there are admittedly some Excludes1 designations I can't wrap my head around, this isn't one of them because discussion of STDs, protection and all that goes with discussion of contraception. Unless someone specifically comes in for STD screening, I wouldn't use it - see Chapter 21 guidelines about screening codes.

 

[klmcginnis]

Hi Kim, well let me ask why you want to bill them together? While there are admittedly some Excludes1 designations I can't wrap my head around, this isn't one of them because discussion of STDs, protection and all that goes with discussion of contraception. Unless someone specifically comes in for STD screening, I wouldn't use it - see Chapter 21 guidelines about screening codes.

Hi Meg,
Thank you for your response. To provide additional context, we are a public health department and routinely perform STI screenings during the same visit as contraceptive services. This has been a longstanding standard practice for us, and we have not experienced denials until recently. That is why I’m reaching out for assistance and would appreciate any insight you can provide.
Thank you,
Kim