Q&A: Clarifying inclusion and exclusion notes

Q: Can you please clarify these 3 areas in the DRG Expert for me? Inclusion notes Exclussion1 notes Exclussion2 notes and how that translates in the coding world?

A: First, let’s talk about the DRG Expert. The DRG Expert is a resource for understanding the methodology of DRG assignment and is not a code book. The terms you are specifically asking about refers to “coding conventions” which can be found in the alphabetical and/or tabular lists within a code book under specific the ICD 10 codes.  The definitions of the coding conventions can also be located in the 2020 Official Coding Guidelines, which I will outline below in the answers for each term you are asking about.

“Inclusions and exclusions,” are terms used in ICD-10-CM code assignment and can be found in the Alphabetical Index and/or Tabular Lists within the code set. Coding conventions, or the rules governing code assignment can be found in the Official Guidelines for Coding and Reporting, and are outlined below:

Inclusion Terms: These are alternate ways a provider can document condition(s) or terms that will map to the same code. The definition can be found under number 11, pg. 10, of the rules governing code assignment can be found in the Official Guidelines for Coding and Reporting, which reads:

Inclusion Terms are a “list of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.”

Excludes 1 Notes: Indicates that an excluded code should never be used at the same time as the code listed above the Exclude1 note used. The definition can be found under number 12A, pg. 11, and reads:

“A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

“An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.”

Excludes 2 Notes: Indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. The definition can be found under 12b, pg. 11, and reads:

“A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.”

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.