Toxic Encephalopathy integral to the F10-F19 Series?

Hello all,

We have received a denial stating that toxic encephalopathy is integral to the F10-F19 series, and that specifically F1123 is a combination code and sufficiently captures encephalopathy and therefore further coding specificity is not allowed per the OCG I.B.9

The actual coding of the patient was poisoning as the PDx, G92 as MCC, and then F1123 was coded as well. We found a coding clinic (1Q 2017 pp.40) stating that G92 is not precluded from being coded along with poisoning. But we cannot find anything regarding the F10-F19 series.

Any help is appreciated!


  • Can you ask the payer to cite the source of their assertion?  I can find no instructional notes at the beginning of Chapter 5, nor can i find any excludes 1 notes in that code range to support what the payer is saying. 

    However the provider may be asserting that encephalopathy is integral to opioid withdrawal (F11.23), a position which i am inclined to concur with clinically. (for that one code not for the entire code range you listed above).

    My question would then be:  Was the "brain malfunction" present only during the withdrawal period (Integral clinically) or was it also present outside the withdrawal period (separately reportable according to guidelines).

    The criteria you must always use is:  Is X ROUTINELY ASSOCIATED with Y?

    Since those characteristics are ROUTINELY associated with the actual withdrawal process, i would agree they are integral for that specific code, DURING the active withdrawal period only.
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