Some payers are denying claims when heart failure or sepsis codes are sequenced as the principal diagnosis because they are misinterpreting the “code first” note at categories I50, Heart failure, and A41, Other sepsis. They are denying the claim based on the belief that the conditions listed in the note are always sequenced first, even though the patient may not have any of the conditions listed. Could you please clarify the intent of the instructional note?
The “code first” note means code first, if present. This instructional note is intended for conditions that have both an underlying etiology and manifestation, and indicates the proper sequencing order: etiology first, followed by the manifestation. However, this instructional note is only applied when the underlying conditions listed in the note are present. If these conditions are not present, the code first note is not applicable.