1. Excludes1. An Excludes1 note is a pure excludes. It means “NOT CODED HERE!”
2. Excludes2. An Excludes2 note represents “Not included here.”
When an Excludes2 note appears under
a code, it is acceptable to use both the code and the Excludes2 code togethe
diabetes type 2 mellitus without complications.” This does not mean that the patient no longer
has diabetes mellitus
assign the code for the current disease of diabetes mellitus (E11.9).
uncertain diagnoses are not reported
condition as many times as the patient receives care or treatment for the condition.
visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
Explanation:For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also
any findings related to the pre-op evaluation.
The answer is, Congestive heart failure, I50.9 because dyspnea and lower extremity edema are not coded as they are symptoms of the patient’s CHF exacerbation.
Additional signs and symptoms that may not be associated routinely with a disease process
should be coded when present.
documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.
the term severe sepsis is not documented.