UnitedHealthcare to Introduce Excludes1 Edits Beginning April 1

As of April 1, UnitedHealthcare will begin using Excludes1 guidelines on claims, in a policy update that applies to “all products, all network and non-network physicians and other qualified health care professionals, outpatient facility claims, Ambulatory Surgical Centers (ASC), Outpatient Surgical Centers (OSC), including, but not limited to, non-network authorized and percent of charge contract physicians, other qualified health care professionals or facilities.”

In their updated policies for commercial and individual exchange plans, Medicare Advantage, and community plans on reimbursement guidelines, UHC states that they “align with the official ICD-10-CM Guidelines for Coding and Reporting, and requires the appropriate diagnosis be submitted on a claim and coded in accordance with the guidelines to be considered for reimbursement.” Among the new guidelines is “Mutually Exclusive Diagnosis Codes defined by Exclude1,” which are themselves defined by the official ICD-10-CM guidelines for Excludes1. 

In short, if you’re billing UHC and you use edit pairs that fall under Excludes1, chances are you’ll see your claim denied. 

What are Excludes1 edits again?

“I definitely know what Excludes1 edits are, but I’d love it if you could refresh everyone else’s memories,” I hear you say. Happy to help! As we discuss in this article, Excludes1 notes indicate that the code listed above can’t be used at the same time as the excluded code—essentially, calling out two conditions that cannot be coded together.

What states are impacted?

In the above updates, UHC also spells out the specific state exemptions as they relate to this new policy, which we’ve listed out below. For states not listed, the new guidelines apply in full. 

Arizona 

Exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

Hawaii 

Hawaii Medicaid allows ICD-10 diagnosis code, Z59.41 to be submitted in the primar position when billed with CPT code, S9977. 

Indiana 

Exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

Kansas 

Kansas Medicaid uses a customized, state identified Inappropriate Primary ICD-10 Diagnosis Codes list. (This list is a combination of codes from ICD-10 Inappropriate Primary DX list and the CMS Medicare Unacceptable Principal Diagnosis Code List). Kansas is exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes1

Kentucky 

Exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

Massachusetts 

Exempt from the Outpatient Primary Diagnosis of this policy. 

Michigan 

Per State Requirement: • Michigan Medicaid allows for Z33.1 and Z39.2 to be billed with T1033 and S9445 for Doulas. • CPT codes 98960, 989621 & 98962 with modifier CG are excluded from this policy for CHLW providers Minnesota Minnesota Medicaid allows for Z33.1 and Z39.1 to be billed with S9445-U4 and 99199-U4. 

Mississippi 

Exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

Missouri

Missouri does not require behavioral health diagnosis for 90791 and 90792. The provider should report the most appropriate ICD-10 diagnostic code. 

Nebraska

Nebraska is exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

New Jersey

New Jersey Medicaid allows the following ICD-10 diagnosis codes to be submitted in the primary position when billed with CPT code 3008F: Z68.51, Z68.52, Z68.53, Z68.54 New Jersey Medicaid allows the following ICD-10 diagnosis code, Z59.01 to be submitted in the primary position when billed with CPT code, H0044, T2038, S5165, & T1028. New Jersey Medicaid is exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

New Mexico

New Mexico Medicaid allows the following CPT codes 98960, 989621 & 98962 to be submitted with ICD-10 diagnosis codes to be submitted in the primary position: Z55.0, Z55.2, Z55.3, Z55.4, Z55.5, Z55.6, Z55.8, Z56.0, Z56.89, Z56.9, Z58.6, Z58.89, Z59.01, Z59.02, Z59.10, Z59.12, Z59.19, Z59.41, Z59.48, Z59.5, Z59.6, Z59.811, Z59.812, Z59.82, Z59.89, Z60.0, Z60.2, Z60.3, Z60.4, Z60.8 

New York 

Plan ID NYCDFHP Product ID NYCD NYCDT NYCDB allows Z65.9 to be primary for following CPT codes 90832, 90834, 90837, 90846, 90847, 90849, 90853. NYEPP, NYCDFHP, NYCHP, NYWEL4ME allows Z59.01 and Z59.02 to be billed as primary DX code on a claim.

North Carolina

North Carolina Medicaid Healthy Opportunities Pilot (HOP) services are exempt from this policy. 

Ohio 

OHIO MMP is excluded from the Outpatient Primary Diagnosis portion of this policy Ohio is exempt from the Inpatient Mutually Exclusive Diagnosis Codes Defined by Excludes 1 

Rhode Island 

Rhode Island Medicaid uses a customized, state identified Inappropriate Primary ICD-10 Diagnosis Codes list which is included in the policy. 

Tennessee 

Tennessee Medicaid allows ICD-10 diagnosis code S06.2X1S in principal position when billed with any of the following CPT codes: 97151-97158, 0362T and 0373T Tennessee Medicaid allows ICD-10 diagnosis codes Z3A.01, Z3A.19-Z3A.42, Z3A.49, O75.85 and O94 in the principal position when billed with the following CPT code A4670 

Texas 

Texas Medicaid does not allow the following category to be submitted in the primary or referenced diagnosis: • Diagnosis in the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3) Texas Medicaid allows for the following ICD-10 diagnosis code to be submitted in the primary position: • Z23 – if immunization is the only service provided during an office visit. 

Virginia 

Virginia Commonwealth Community Care Plus (CCC Plus) HCBS plan includes H2000 as an HCBS service. HCBS services are exempt from this policy. 

Wisconsin 

Wisconsin Medicaid allows the following ICD-10 diagnosis codes to be submitted in the primary position when billed with CPT code 3008F: Z68.51, Z68.52, Z68.53, Z68.54.

What do I need to do?

Fortunately for WebPT Members, Excludes1 edits get flagged within the EMR to help you avoid the issue. That said, it's always good to be aware of payer rules on the chance you miss those alerts.