ICD-10-CM Excludes 1 Notes Policy

Date Issued: 12/6/2018

EmblemHealth will deny claim lines reported with mutually exclusive ICD-10-CM code combinations as defined by the Excludes 1 Notes guideline policy. Excludes 1 Notes show medical conditions that cannot occur together, e.g., congenital versus acquired form of the same condition. Because a patient cannot have both forms of the condition, a correctly coded claim cannot have both versions of the ICDs. The conditions are mutually exclusive, as should be the codes used on claims.

The Excludes 1 Notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note is applicable to all codes in the section.

Example:

The Excludes 1 note in the ICD-10 CM Manual associated to code H73.0 is ”acute myringitis with otitis media (H65, H66).”

When a code from range H73.0-H73.099 (acute myringitis) is associated to the same claim line as a code in either the range H65-H65.93 (nonsuppurative otitis media) or the range H66-H66.93 (suppurative and unspecified otitis media), then the claim line will be denied.