CHAPTER SIX

Instructional Notes

Follow Instructional Notes

Individual codes and code categories may also include notes that give additional direction for correctly using the code(s). It’s very important to review and follow these instructional notes, when appropriate. Here are the main types of notes you’ll see in the ICD-10-CM code list.

Includes Notes
Excludes Notes
Code First & Use Additional Notes
Code Also Notes

Includes notes appear immediately after certain categories or codes to further define, clarify, or give examples of the content of a code category. The examples in these notes usually aren’t exhaustive.

Example (highlighted below):

S06 Intracranial injury

Includes: traumatic brain injury

Inclusion terms also function like includes notes. They’re added under certain codes to indicate some of the conditions the code may also describe. Inclusion terms aren’t exhaustive.

Example (highlighted below):

R13.19 Other dysphagia
Cervical dysphagia
Neurogenic dysphagia

There are two types of Excludes notes that indicate whether certain codes can be reported together on the claim.

Excludes1 notes indicate when two or more codes may never be reported together because they can’t occur together—such as the congenital form of a condition versus an acquired form of the same condition.
Excludes2 notes indicate codes that may be reported together because the conditions may occur together, even if they’re unrelated. This isn’t intuitive, but you can think of an Excludes2 note as a “see also” note rather than an exclusion, meaning that the codes can be reported together.

Example

In this example, the Excludes1 note indicates that you can’t report a developmental phonological (articulation) disorder (F80.0) with speech disorders due to apraxia or aphasia (R47.01) or apraxia (R48.2).

The Excludes2 note tells you that a phonological (articulation) disorder (F80.0) can be reported with other co-existing developmental speech and language disorders, if appropriate.

F80.0 Phonological disorder
Phonological developmental disorder

Excludes1: speech articulation impairment due to aphasia NOS (R47.01)
speech articulation impairment due to apraxia (R48.2)

Excludes2: speech articulation impairment due to hearing loss (F80.4)
speech articulation impairment due to intellectual disabilities (F70-F79)
speech articulation impairment with expressive language developmental disorder (F80.1)
speech articulation impairment with mixed receptive expressive language developmental disorder (F80.2)

Code first and use additional notes indicate when there’s an etiology (cause) and manifestation (sign, symptom, or disorder) relationship among codes.

In those cases, there will be a use additional code note at the etiology code, and a code first note at the manifestation code instructing you to sequence the underlying condition first, followed by the manifestation.

Example

I69.391 Dysphagia following cerebral infarction

Use additional code to identify type of dysphagia, if know (R13.1-)

R13.1 Dysphagia

Code first, if applicable, Dysphagia following cerebral vascular disease (I69. with final characters -91)

In this example, dysphagia due to stroke (I69.391) represents the etiology code, which instructs you to report a second code that more specifically describes the type of dysphagia (R13.1- series). This allows you to provide a more complete description of the patient’s condition.

Code also means two or more codes may be needed to fully describe a condition, but sequencing of the codes is at the discretion of the clinician depending on the severity of the conditions and the reason for the visit.

Example 

F80.4 Speech and language development delay due to hearing loss

Code also type of hearing loss (H90.‐, H91.‐)

In this example, the code also note indicates that you need to provide more information about the type of hearing loss associated with the speech and language disorder. Since this instruction is to code also rather than to code first, the order of the codes is up to you.

CODING TIP

If there is no note indicating sequencing, default to the coding fundamental for primary and secondary diagnoses. In other words, code the treating diagnosis first, followed by secondary or medical diagnosis codes.

Check Your Understanding!

An Excludes1 note means I should not report the listed codes together for the same patient.

True

False

CORRECT

Your're right! Excludes1 notes tell you which codes should never be reported together. It’s very important to follow the Excludes1 notes to avoid claims denials.

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INCORRECT

That's not it. The statement is true. Excludes1 notes tell you which codes should never be reported together. It’s very important to follow the Excludes1 notes to avoid claims denials.