ICD-10 Mutually Exclusive

tlc45801

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Lima, OH
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We are receiving quite a few denials from Ohio Anthem BC/BS due to mutually exclusive codes BUT I'm not sure they are correct. E78.00 (pure hypercholesterolemia, unsp) and E29.1 (testicular hypofunction) is just one example. It seems since October this has been happening regularly. Just curious if other offices are seeing this too and how you are resolving the issue?
 

mitchellde

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Columbia, MO
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for the example you gave E78.00 with E29.1 the edit for mutually exclusive diagnosis is correct.
look under the subsection
Metabolic disorders (E70-E88)
Type 1 Excludes: •androgen insensitivity syndrome (E34.5-)
•congenital adrenal hyperplasia (E25.0)
•Ehlers-Danlos syndrome (Q79.6)
•hemolytic anemias attributable to enzyme disorders (D55.-)
•Marfan's syndrome (Q87.4)
•5-alpha-reductase deficiency (E29.1)
excludes notes at the beginning of a section applies to all codes in that section

I would look at all of the other combinations thoroughly to determine if a similar situation exits.
 
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Location
Matthews, GA
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for the example you gave E78.00 with E29.1 the edit for mutually exclusive diagnosis is correct.
look under the subsection
Metabolic disorders (E70-E88)
Type 1 Excludes: •androgen insensitivity syndrome (E34.5-)
•congenital adrenal hyperplasia (E25.0)
•Ehlers-Danlos syndrome (Q79.6)
•hemolytic anemias attributable to enzyme disorders (D55.-)
•Marfan's syndrome (Q87.4)
•5-alpha-reductase deficiency (E29.1)
excludes notes at the beginning of a section applies to all codes in that section

I would look at all of the other combinations thoroughly to determine if a similar situation exits.

We are having the same issues with dozens of claims. How are we supposed to set up coding software to help catch these before they go to an insurance?
 

mitchellde

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Columbia, MO
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It is a daunting task and because these can change with the code updates it makes it even harder to maintain, I have not worked with a software program to date that will alert to the edits. It is to a coder to know to look for these and where to find them in a code book.
 
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