Mutually exclusive ICD-10 codes
The Advocacy Council regularly receives queries from members on how to correctly code specific scenarios. Recently we received requests for assistance from two allergy practices, one in Ohio and one in California, for denial of claims due to the J30 series of ICD-10 diagnosis codes. While the carriers and regions of the country were different, the denials were the same and disrupted each practice’s cash flow.
The specific requests for assistance and corresponding recommendations are outlined below.
Office 1: Recently, our office has been getting rejections for claims with diagnoses J30.89, J30.81 or J30.1 (allergic rhinitis codes) when used with J31.0 (nonallergic rhinitis). I think this combination is appropriate for patients with mixed rhinitis (AR + NAR).
The Advocacy Council coding experts explain: Even though, as allergists, we know that a patient can be diagnosed as having both allergic rhinitis AND nonallergic rhinitis that is not always how the managed care organizations see this. They (or their computers) look at this as specific rhinitis codes (J30) being mixed with rhinitis NOS (J31.0) and that is an “Excludes 1” situation – J30.89, J30.81 or J30.1 (allergic rhinitis codes) when used together with J31.0 (nonallergic rhinitis).
Office 2: We have a patient on allergy IT with diagnoses of J30.1, J30.81, J30.89 and J45.909. The claim was rejected as “mutually exclusive.”
The Advocacy Council coding experts explain: Again, according to the ICD-10 guides, the payor in this example looks at this as mutually exclusive codes (according to ICD-10). You may not be able to use that asthma code with the rhinitis codes. The exclusion reads:
J30 - Vasomotor and allergic rhinitis Includes: spasmodic rhinorrhea excludes 1: allergic rhinitis with asthma (bronchial) (J45.909) rhinitis NOS (J31.0)
In other words, you cannot use the J30 codes with either J31.0 or J45.909.
This may not seem clinically correct, but ICD-10 will need to be changed before the two codes can be billed together. If you have tested the patient and they are allergic, you may not want to use the J30.0 for nonallergic or vasomotor rhinitis. You can use the different allergic rhinitis codes together since there are different types of allergic rhinitis.
You can save staff time by having them check to make sure the carrier approves the ICD-10 codes used. Go to the carrier’s website and look for the list of “pairings” – CPT codes matched to ICD-10 codes – for which they will reimburse. If your ICD-10 code is not matched with the CPT you’re using, your claim is going to be denied.
Unfortunately, there is no standardization and carriers may differ in which ICD-10 codes they will pay. But spending some time before submitting claims can save a mountain of paper work and staff time trying to appeal later.