Updated Blue Cross policy for diagnosis codes will align with ICD‑10‑CM guidelines

In support of correct coding and payment accuracy, please be aware that Blue Cross Blue Shield of Michigan will be updating our payment policies relating to diagnosis codes. These updates will reflect adherence to:

• The “Excludes 1” notations in the ICD-10-CM diagnosis code set
• Unacceptable principal diagnosis guidelines

‘Excludes 1’ notations

The “Excludes 1” notations in the ICD-10-CM diagnosis code set indicate that the excluded code listed in the notation can’t be billed with the codes listed above the notation. The two conditions shouldn’t be reported together under any circumstance (for example, a congenital form versus an acquired form of the same condition). These conditions are mutually exclusive code combinations.

“Exclude 1” notations are listed within ICD-10-CM chapter levels, under ICD-10-CM codes, or elsewhere in the code book.

Keep the following in mind:

• These notations are located under the applicable section heading or specific ICD-10-CM code to which the notation is applicable.

• When the notation is located following a section heading, then the notation is applicable to all codes in the section.

Claim lines reported with mutually exclusive code combinations, according to the guideline policy for “Excludes 1” notations, may receive a denial. If you receive a denial, you’ll need to submit a corrected claim.

Unacceptable principal diagnosis

According to the ICD-10-CM manual, the following is considered unacceptable as a principal diagnosis for an outpatient prospective payment system, or OPPS, claim:

• Supplemental or additional diagnosis codes that identify the infectious agent in diseases classified elsewhere

Blue Cross will deny all services when the principal diagnosis is on the unacceptable principal diagnosis list for OPPS claims.

This policy aligns with Centers for Medicare & Medicaid Services and the ICD-10-CM manual.

Claim lines reported with an unacceptable principal diagnosis may receive a denial. You’ll want to ensure that submitted claims reflect the services performed and the patient’s condition.