Coding for Upper Respiratory Conditions and Abdominal Pain: No Exclusions Here!
Upper respiratory conditions and abdominal pain are the top two diagnoses treated at urgent care centers. While these conditions may be common, selecting the right codes to avoid denials can be complex.
Excludes 1 notes appear when you choose two codes that can’t be used together. Basically, Excludes 1 means “Not coded here!” These coding errors are easy to make. It takes education and experience to understand and become familiar with these common coding mistakes.
Revisiting Coding from Symptoms to Diagnosis
Healthcare providers often start with codes related to signs and symptoms to document clinical information and observations. Providers (or coders) may need to revisit and eliminate these codes after reaching a specific, definitive diagnosis.
Common Errors:
A patient has a sore throat, congestion, and fever. The provider orders a rapid strep test and a Covid test, and includes the following ICD-10-CM codes:
- J02.9- Acute pharyngitis, unspecified
- R09.81- nasal congestion
- R50.9- Fever, unspecified
- J00- Acute nasopharyngitis [common cold]
This claim would be denied because an Excludes 1 note states J02.9 cannot be coded with J00. Remove J02.9 because it is a sign/symptom of acute nasopharyngitis.
A patient presents with a sore throat and fever. The provider observes inflamed tonsils, orders a rapid strep test, and includes theses ICD-10-CM codes:
- J02.9- Acute pharyngitis, unspecified
- R50.9- Fever, unspecified
- J03.90 Acute tonsillitis
This claim would be denied because an Excludes1 note states J02.9 cannot be coded with J03.90. Remove J02.9 because it is a sign/symptom of Acute tonsillitis.
A patient has a sore throat, cough, fever, and runny nose. The provider orders a rapid strep test and diagnoses streptococcal pharyngitis. All symptoms are addressed and coded:
- J02.0- Streptococcal pharyngitis
- R50.9- Fever, unspecified
- R05.9- Cough
- R09.81- Nasal Congestion
- J06.9- Acute upper respiratory infection, unspecified
This claim would be denied because an Excludes 1 note states J02.0 cannot be coded with J06.9. Remove J02.0 because it is a sign/symptom of acute upper respiratory infection, unspecified.
A patient arrives experiencing an asthma attack. Despite an initial nebulizer treatment, they continue to wheeze, so the provider prescribes an additional nebulizer treatment and includes these codes:
- R06.2- Wheezing
- J45.901- Unspecified asthma with (acute) exacerbation
This claim would be denied because an Excludes 1 note states R06.2 cannot be coded with J45.901. Remove R06.2 because it is a sign/symptom of asthma.
A patient complains of generalized body aches, accompanied by a fluctuating fever and intermittent abdominal pain. The provider lists these codes:
- R52- Pain, unspecified (body aches)
- R50.9- Fever, unspecified
- R10.9- Abdominal pain, unspecified
- J09.x3- Influenza due to identified novel influenza A virus with gastrointestinal manifestations.
This claim would be denied because an Excludes 1 note states R52 cannot be coded with R10.9. Remove R52 because R10.9 is a more specified abdominal pain.
Ideally, the goal is to avoid Excludes 1 discrepancies instead of fixing them. It’s important to understand what will initiate an Excludes1 note to prevent errors and ensure claims are coded properly the first time.
Contact CodeEMR
For more information about proper coding to avoid Excludes 1 notes and other costly errors, contact Paul Ferrazza, Vice President Coding Business Development, at 401-529-0109 or paul.ferrazza@codeemr.com.
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