ICD-10-CM 2017 Guideline Changes: Excludes1 Notes, "If Applicable", and More!

October 1, 2016 will be bringing significant updates to the ICD-10-CM guidelines and this segment of “In the kNOW” will highlight some of those updates.  Other editions of “In the kNOW” will continue to explore more of these changes.

The first updates to examine are in Section I of the guidelines which address conventions, general coding guidelines, and chapter specific guidelines.  Section I. A (Conventions for the ICD-10-CM) has four changes, the first of which addresses Excludes1 notes (I.A.12.a).  An Excludes1 note tells coders that two conditions should never be coded together.  This update explains that there is an exception to this rule that occurs when the two conditions are not related.  If in doubt about whether or not the conditions are related, coders are instructed to query the physician.  This guideline update is an affirmation of the Coding Clinic advice published in 4^th quarter 2015 which provided the same guidance.

A smaller change is found at Section I.A.13 (Etiology/manifestation convention) where the phrase “if applicable” was inserted to clarify the ICD-10-CM’s convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

Section I.A.15 has perhaps the most significant change of all and that is guidance on the interpretation and usage of the term “with”.  Coders have known that “with” can be interpreted to mean “associated with” or “due to”.  Now coders are instructed that there is a presumption of a causal relationship whenever two conditions are linked by those words or phrases whether in the Alphabetic Index or the Tabular List.  Coders are further directed to code those conditions as if they are related even in the event there in no physician documentation that officially links them, unless there is clear documentation that the conditions are unrelated.  If these relational terms are absent in the classification, then the documentation provided by the physician must link the conditions in order to code them as related.  The content of this guideline is supported by the 1^st quarter 2016 Coding Clinic’s advice on coding “diabetes, with.”  

The final guideline change for Section I.A is a new guideline at Section I.A.19 (Code assignment and Clinical Criteria).  This guideline clarifies that diagnosis codes are to be based on the provider’s diagnostic statement that the condition exists.  This statement is sufficient documentation in order to assign a code, and coder’s do not have to base the code assignment on the clinical criteria that a provider may have used to determine the diagnosis.  

These final two guideline changes are sure to generate a great deal of discussion over the next months.  Stay tuned for further clarifications should they become available.

This link will direct you to the CMS webpage for everything ICD-10-CM related: https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.