Clinical Criteria and Excludes 1 Note

 

ICD-10-CM guidelines – “Code assignment and clinical criteria” Update:

 Code assignment and clinical criteria: 

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

 Instructions to coders and CDSs: 

We always code based on narrative diagnosis documentation from the physician when the documentation appears reliable.

 We never code from clinical criteria or clinical indicators alone.

 Coders and CDSs must continue to review records to ensure that documentation/clinical indicators support the stated diagnoses.

 There must be appropriate clinical criteria/indicators before a query can be initiated.

EXCLUDES 1:

An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note…

 An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.

 For example, code F45.8, Other somatoform disorders, has an Excludes 1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding.  However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.