Excludes1 diagnosis pairs are resolved by the book on anesthesia, surgery, E/M and radiology claims, plus obstetric modifier and validation refinements
A labor epidural line (01967) bills the directed or teaching modifiers only when the record shows that an anesthesiologist was there for the epidural. The autocoder compares the time of the 01967 line with the documented time of each anesthesiologist on the case. This applies when a CRNA, an anesthesiologist assistant (AA), or a resident placed the epidural.
The time of an anesthesiologist overlaps. The line bills the directed modifiers from your medical direction settings with that anesthesiologist, for example QK for the anesthesiologist and QX on the CRNA line. At a shift change, the night anesthesiologist who directed the epidural can be a different person from the day anesthesiologist who did the cesarean.
The time of no anesthesiologist overlaps. The case gets one question. For a CRNA placer, the line bills your CRNA-alone setting (QZ with the shipped settings) until the direction is confirmed.
An AA or a resident placed the epidural. An AA or a resident cannot bill without a directing or teaching anesthesiologist. So the line keeps the directed modifiers, and the coder decides.
For example: a CRNA places a labor epidural early in the morning, and the anesthesiologist's documented time starts at the cesarean delivery hours later. The 01967 line bills QZ, and the coder confirms whether the anesthesiologist directed the placement.
Labor Epidural Direction Not Shown (new, ob_labor_epidural_direction_unverified). Reviewer: a coder. Type: Compliance, severity 8. It names the placer, the epidural time and the time of each anesthesiologist on the case, and asks whether an anesthesiologist medically directed the placement. In HANK Claim Maker, this Compliance alert pulls a coder by default. It is the one alert for the line: the CRNA-alone audit alert does not appear beside it.
When your facility requires a directing anesthesiologist for every CRNA line (the hardstop CRNA-alone setting), the CRNA line bills no payment modifier while the question is open. The question then follows that setting: it is a Hardstop, severity 10, for your charge entry team.
In a sample of 2,336 recent fully automated anesthesia cases, 1.4% had a 01967 line, so this question can apply to at most 1.4% of such cases.
When no anesthesiologist has documented time at all, the existing missing-times alert asks instead, so the case gets one question, not two.
Read the labor note. If an anesthesiologist directed the placement, bill the directed modifiers with that anesthesiologist. If not, keep the non-directed billing for a CRNA, or correct the line for an AA or a resident.
An anesthesiologist who places the epidural never gets this question.
Your organization can silence this alert or change who it asks. Your CRNA-alone setting decides what a CRNA placer bills while the question is open, and who gets the question. Ask your Hank representative.
Diagnosis pairs the classification says cannot be coded together are now resolved by the book, and you see a note instead of a question.
An Excludes1 note in the ICD-10-CM Tabular List says that two conditions are not coded together. For example, the note at K83.1 (obstruction of bile duct) excludes "obstruction of bile duct with cholelithiasis (K80.-)". The autocoder now reads these notes for the fiscal year of the date of service. It gives the diagnosis check each conflicting pair, the note, and any combination code that the classification offers. Then it verifies the result on the finished claim. This applies to anesthesia, surgery, E/M and radiology claims.
Each pair ends in one of these outcomes:
A combination code describes both conditions. The claim bills the combination code alone. For example, K80.51 (calculus of bile duct without cholangitis or cholecystitis with obstruction) replaces K80.50 and K83.1 when the record states that the stone caused the obstruction. The autocoder confirms that the combination code is billable, belongs to the note's family, is offered for the note, is not less specific, and does not start a new conflict. When the code is not billable, is outside the note's family, or starts a new conflict, the two original diagnoses come back and a coder gets one question. When the code only fails the offered or specificity check, the code stays and a coder gets one question.
The record supports only one diagnosis. The claim keeps that diagnosis.
The record states that the two conditions are not related. The claim keeps both diagnoses. An Informational note quotes the documented cause and records the payer edit risk.
The record does not settle the pair. A coder gets one question.
Excludes1 Diagnosis Pair Resolved (new). Reviewer: a coder. Type: Informational, severity 3. It records how the pair was resolved. In HANK Claim Maker, this Informational alert does not stop the case.
Excludes1 Diagnosis Pair Needs Review (new). Reviewer: a coder. Type: Compliance, severity 7. It names both diagnoses, the note, what the autocoder kept and removed, and any combination code that the classification offers. In HANK Claim Maker, this Compliance alert pulls a coder by default.
ClaimCleaner Question: Diagnosis Convention Conflict. When the autocoder answers an Excludes1 pair, this alert no longer appears for the same pair. You get one question per pair at most.
Diagnosis Order Changed for a Code First Note (new). Reviewer: a coder. Type: Informational, severity 3. When a line carries a manifestation code and the etiology that its "code first" note names, the autocoder puts the etiology first. For example, D57.1 (sickle-cell disease without crisis) now comes before M90.551 (osteonecrosis in diseases classified elsewhere). On an anesthesia line with a diagnosis limit, the etiology now stays on the line. Only the order changes. In HANK Claim Maker, this Informational alert does not stop the case. This applies to anesthesia, surgery and E/M claims, and to radiology claims when your organization turns on the radiology first-listed diagnosis check.
ClaimCleaner ICD Edit Applied (radiology). This alert no longer fires for an Excludes1 pair. The autocoder resolves the pair from the report, as described above. The alert still fires when validation removes a header code that is not billable.
Validator Added a New ICD (radiology). This alert no longer fires for a combination code that the classification offers for a pair on the claim, when the finished claim passes the checks above.
Automated claim validation (ClaimCleaner) now runs two times on an anesthesia claim. The second run checks the finished claim, after the diagnosis check and the Excludes1 resolution. So a combination code that the autocoder applies is checked before the claim reaches you. ClaimCleaner questions come from the second run only, so a question never names a diagnosis that has already left the claim. If the first run fails, the claim carries one failure alert, not two.
The payment modifier on a labor epidural line (01967) now follows the provider who placed the epidural and your medical direction settings, the same as on every other anesthesia line. For example, with the shipped settings, an anesthesiologist who places the epidural alone bills AA. Before, 01967 received a payment modifier only when a CRNA worked alone.
Modifier 76 no longer appears on 01967 or on the add-on codes 01968 and 01969. Validation added 76 to 01968 because both obstetric lines carry the same delivery procedure. The autocoder now removes that 76, and the Modifier Added To An Anesthesia Code alert for it no longer appears. The claim records the removal.
When a cesarean delivery follows a labor epidural, the autocoder bills the 01968 add-on with the 01967 line.
When a cesarean hysterectomy follows a labor epidural, the autocoder now bills the 01969 add-on with the 01967 line. The 01969 line carries the time of the cesarean hysterectomy, and 01967 keeps the labor time.
Records with no date of service. When no date of service is found, the autocoder checks code validity against the current code year and labels that year as an assumption. The claim records the assumed year and the reason. Radiology coding now uses the claim's date of service when the report itself has no date.
Lines that validation adds. When validation adds a line to the claim, the autocoder does not use that line and records the count on the claim. The ClaimCleaner Processing Failed alert no longer appears for it.
Corrected diagnoses on every line. When the diagnosis check corrects a code that several lines share, every line now gets the corrected code.
Processing-rule alerts. A facility processing rule that creates an alert with no alert type now creates an Informational alert, and nobody is pulled. The exception is the three rule types that remove billed time or a billed line (a procedure with no times, a nerve block that bills as anesthesia time, and discontinuous times): there the alert is Financial and asks a coder. A rule with no reviewer role now routes its alert to a coder, and a configured role always applies. If one of your rules must stop the case, give it the type Hardstop, Compliance or Financial. The autocoder's own shipped rules already set their type.
Excludes1 posture. Your organization can ask for a coder question on every Excludes1 pair that the claim still bills, or turn the Excludes1 resolution off. Ask your Hank representative.
On anesthesia, surgery and E/M claims, expect fewer diagnosis questions and more Informational notes. Read Excludes1 Diagnosis Pair Resolved when you audit why a combination code is on the claim or why a diagnosis left it.
On radiology claims, each Excludes1 pair now ends in an Informational note or in one question. When the report settles the pair, you see Excludes1 Diagnosis Pair Resolved. When the report does not settle it, a coder gets one question. The autocoder no longer removes a diagnosis from an Excludes1 pair without a note, so you can see a small number of new questions on radiology claims.
A question stays when the record does not settle a pair. Read the record, then bill the combination code, remove one diagnosis, or keep both only when the record states that the conditions are not related.
For dates of service on or after October 1, 2026, the Excludes1 resolution starts when the fiscal year 2027 notes are loaded. Until then, the ClaimCleaner Question: Diagnosis Convention Conflict alert asks about those pairs.
Automated claim validation (ClaimCleaner) checks an anesthesia claim two times. The second check runs on the finished claim, after the claim-wide diagnosis check. The second check now keeps every diagnosis that the diagnosis check decided from the record.
A diagnosis the diagnosis check decided. When the second check proposes to add, remove, or swap that diagnosis, the autocoder does not apply the change. The claim records the proposed change and the rule that proposed it.
Every other diagnosis. The second check works as before. For example, it still removes a code that the autocoder added and that is not valid for the date of service.
A claim that did not change. When the claim did not change after the first check, the autocoder does not send it again. The findings of the first check apply.
For example: the record documents a left knee replacement, and the diagnosis check keeps Z96.652 (presence of left artificial knee joint). The second check no longer swaps that code for the right side.
ClaimCleaner Added ICD Code (Compliance, severity 8, reviewer: a coder). This alert no longer appears for a change that the autocoder did not apply on the second check. The alert still appears when validation adds a diagnosis that the diagnosis check did not decide. In HANK Claim Maker, this Compliance alert pulls a coder by default.
ClaimCleaner Question alerts. When the rule of that finding is on the autocoder's review list, for example a side modifier that disagrees with the diagnosis, or a code that validation reads as not valid for the date of service, the question still appears, because two checks disagree about the claim. The question states what the diagnosis check decided, the codes and modifiers on the line, and the change that validation proposed. A finding on any other rule stays recorded on the claim and does not raise a question.
Your facility processing rules can create an alert. When a rule creates an alert and does not set an alert type, the autocoder now picks the type from what the rule does to the claim.
The rule removes billed time or a billed line. The alert is Financial and asks a coder. This covers three rule types: a procedure with no times (the line moves to the bundled list), a nerve block that bills as anesthesia time instead of a flat fee, and discontinuous anesthesia times (the gap minutes leave the billed units).
Every other rule. The alert is Informational and nobody is pulled.
A rule that sets its own alert type always keeps it. The autocoder's shipped rules already set their type, so their alerts do not change.
Processing-rule alerts with no alert type. Reviewer: a coder, unless the rule names another reviewer. Type: Financial on the three rule types above, Informational on every other rule. In HANK Claim Maker, a Financial alert for a coder stops the case until a coder reviews it, and an Informational alert does not stop the case.
If one of your rules on these three types must not stop the case, set its alert type to Informational.
If a rule of another type must stop the case, set its alert type to Hardstop, Compliance or Financial.
When your configuration loads, the autocoder logs each rule that creates an alert without a type. Ask your Hank representative to review those rules with you and to set the type you want.
Every finished claim runs through automated claim validation before it reaches you. Validation checks NCCI procedure pairs, add-on code rules, Medicare payment rules, coverage articles, code validity for the date of service, and diagnosis conventions. This release changes what you see from it in two ways.
Validation alerts now name the rule. Before this release, an alert read "Modifier 59 added by ClaimCleaner" and stopped there. You could see the change but not the rule behind it, so confirming the change meant looking the rule up yourself. Each of these alerts now ends with the rule, in the form "Reason: [the rule's own explanation] [the rule id]". Read that sentence first. It names the payment rule or coding convention that produced the change. The alerts themselves are unchanged: same names, same types, same severities.
The alerts that gained the reason are Anesthesia Code Changed, Diagnosis Added, Modifier Added To An Anesthesia Code, Modifier Added To A Surgical Code, Line Left With No Code, and Line Removed By Validation.
Ten new alerts carry the questions validation could not answer. Validation also reports problems it will not correct on its own, because the answer needs the record, not a rule. Until now none of those reports reached a coder. Ten new alerts carry the ones worth your time:
Diagnosis Convention Conflict: two diagnoses on the finished claim break an ICD-10-CM Excludes1 note. When the claim-wide diagnosis check could not decide between the two, the alert names the diagnosis it kept and the diagnosis it removed. Findings on other diagnosis conventions are recorded on the claim and raise no alert.
Add-On Code Without Its Primary: the claim bills a CMS type-1 add-on and carries none of the primary codes CMS requires with it.
Age Or Sex Conflicts With The Code: the patient age or sex conflicts with a billed diagnosis or procedure.
Side Modifier Disagrees With The Diagnosis: the modifier names one side and the diagnosis names the other, or no diagnosis supports the side billed.
Evaluation And Management Modifier Against A Global Period: modifier 25, 57 or 24 does not fit the procedure's global period.
NCCI Procedure Pair: two codes form a procedure-to-procedure pair and the autocoder did not apply the bypass.
Coverage Article Disagrees With The Diagnosis: a Medicare coverage article covers none of the billed diagnoses, or states one does not support medical necessity.
Code Not Valid For The Date Of Service: validation and the autocoder disagree on whether a billed code is valid for that year.
Anesthesia Code Suggested But Not Billed: validation suggests an anesthesia code the claim does not carry.
Units Over The Medically Unlikely Edit: the units billed for a code exceed its NCCI Medically Unlikely Edit (MUE). The autocoder never changes units. When validation would reduce units above an absolute limit, the line still bills the original units and this alert asks you to confirm the units the record supports.
Each alert reads "ClaimCleaner:" then the rule's explanation and its rule id. The type and the severity come from the rule. Every rule in this set classifies as Compliance today. The alert carries the rule's own classification, so a future validation rule could arrive as Financial. One exception: the units alert for a single line over an absolute limit is Compliance, severity 5, set by the autocoder, because validation marks that finding Informational after reducing the units in its own copy of the claim.
What to look out for. Expect a small number of new alerts, not a flood. An alert appears only when five conditions are true.
The rule is on the autocoder's review list. The rule's own classification is not Informational. Validation did not fix the problem itself. The line is still billable on the finished claim. The diagnosis problem that the finding names is still on the finished claim.
For an Excludes1 pair, the alert stays while the diagnosis that carries the Excludes1 note, or another code under the same note, is still billed together with a diagnosis from the note's family. When the autocoder cannot read the note from the finding, it checks the two named diagnoses instead.
The autocoder removes an alert again when it later moves the line out of billing, or when the diagnosis problem that the finding names is no longer on the finished claim. If the claim-wide diagnosis check replaces the diagnosis that carries the note with another code under the same note, or replaces the other diagnosis with another code from the note's family, the alert stays, because the conflict is still on the claim. The alert then also names the pair that the claim bills now. When the diagnosis check leaves two findings on the same pair of billed diagnoses, or two conflicts land on one line, you get one alert that names each pair. Conflicts on different lines raise one alert each. For the other diagnosis findings, and for an Excludes1 finding whose note the autocoder cannot read, a replacement or removal of a named diagnosis removes the alert. A finding about a diagnosis that is missing, for example no diagnosis for the side billed or no diagnosis that a coverage article covers, stays, because the autocoder cannot tell whether a diagnosis added later qualifies.
Start with the rule text in the alert, then check the record for the fact the rule needs: the side of service, the patient demographics, the covered diagnosis, the distinct service, or the units of service.
If a family of these questions does not fit your workflow, your organization can silence it or route it to a different reviewer role. Ask your Hank representative. A silenced alert still appears as an informational note.
A nerve block line, and the ultrasound guidance line that goes with it,
carries only the diagnoses documented for the block itself. That is
normally the post-procedural pain code. It does not carry the patient's
other conditions, because the reason for the block is the reason for the
block, not every condition on the chart.
Claim cleaning runs after coding and can add a diagnosis to a line. When it
adds one to a block line that the line is not allowed to carry, the
autocoder removes it again. That part is not new.
What is new is that you can see it. Before this change the removal happened
quietly, and the system also cleared the "added by claim cleaner" note for
that code, so nothing on the claim showed that a diagnosis had come and
gone. Now the claim carries an informational alert, "Diagnosis Added After
Claim Cleaning Was Removed From a Block Line". The alert names the codes it
removed, names the diagnoses the line kept, and identifies the line.
Nothing about which diagnoses get removed has changed.
Expect this alert to be rare. Claim cleaning no longer copies the main
anesthesia line's diagnoses onto the other lines, so the situation this
cleanup was built for does not arise any more. That is exactly why the
alert is worth having: if a diagnosis does get added to a block line today,
something unusual put it there, and you should look at it rather than have
it disappear without a record.
Read the removed codes in the alert. Confirm that none of them is the
correct indication for the block. In almost every case the removed code is
a condition that belongs on the main anesthesia line instead.
If one of the removed codes IS the correct indication for the block, add it
to the block line and tell your coding lead. The same code will be removed
again on the next claim of that shape, so it is worth reporting rather than
fixing one claim at a time.
The alert follows your existing block-line diagnosis setting. On the
shipped default, a block line keeps only the G89 pain-family codes. A
facility configured to keep the documented pain-location codes as well will
see the alert less often. A facility that has turned the policy off
entirely will never see it, because nothing is removed.
Medicare Advantage and managed Medicaid plans follow the Medicare
colonoscopy rules. The autocoder used to pick the payer rules from the plan
name alone. A plan whose name carries no Medicare or Medicaid marker, for
example Humana Gold Plus, Keystone 65, Devoted Health, or AmeriHealth Caritas,
could get the commercial rules of the company that administers the plan. The
autocoder now also reads the insurance type recorded on the case. These plans
get the Medicare or Medicaid row. A recent audit found such plans on about 2
percent of cases.
A surveillance colonoscopy is billed as a screening for every payer except
three. Cigna, UHC, and BCBS Nebraska treat surveillance as diagnostic. That
list is complete. Every other payer treats a personal history of colon polyps
as a high-risk screening. This includes Medicare, Medicaid, VA, and Tricare.
In testing, the autocoder could apply a Medicare surveillance exception that
does not exist and produce 00811. The same record now produces 00812.
The discontinuous time alert no longer fires on a labor epidural with a
cesarean delivery. The autocoder now groups the anesthesia time segments by
anesthesia code before it counts them. A labor epidural line and a cesarean
delivery line are two services, not a break in one anesthetic. A provider
handover also does not count as a break when the two segments touch, for
example one segment that ends at 07:00 and the next that starts at 07:01. A
true gap inside one anesthesia code still raises the alert.
The claim itself does not change. The total minutes and the combined time
range stay the same. Only the alert changes.
Obstetric claims show fewer FINANCIAL alerts at severity 4. Before this
change, this alert was often the only reason a coder had to open a labor
epidural claim.
The gap that counts as a break is 5 minutes by default. Your facility can
change this value. Tell your Hank representative if you want a different
value.
On a GI case, read the rationale first. It names the payer bucket and the
intent that the autocoder used, so you can check the result fast.
If a Medicare Advantage or a managed Medicaid case still gets commercial
colonoscopy rules, check the insurance type recorded on the case, then tell
your Hank representative.
Many practices send the comprehensive anesthesia record for an acute pain
service round. That record still contains the original surgery
documentation. Before this change, the autocoder coded the SURGERY from
those packets a second time. That created a duplicate of a claim you had
already billed on the surgery day.
Now the autocoder detects the pain-round visit and codes THAT visit:
01996, one unit when the provider managed an epidural or spinal
catheter that was still in place, on a day after catheter placement.
This is a flat daily fee. It has no anesthesia time and no physical
status modifier. That is correct for 01996.
Subsequent hospital care (99231-99233) when the provider rounded on a
peripheral nerve catheter, for example an interscalene or adductor canal
catheter. Payer rules do not allow 01996 for these catheters.
No charge when the visit does not support a billable service, for
example a check on the same day the catheter was placed. The claim then
carries the alert "No Billable Pain-Round Service" with the exact reason.
The claim date of service is the date of the ROUND, not the surgery date.
The primary diagnosis is acute postprocedural pain (G89.18).
Pain-round claims with 01996 show one unit and NO minutes. Do not add
time to these lines.
If a packet mixes surgery documentation with a partial pain-round note
and the autocoder cannot decide which visit to bill, the claim holds with
the alert "Possible Pain-Round Packet Coded as Surgery". A person must
confirm the correct visit before the claim releases.
If the record does not show that the surgeon handed pain management to
the anesthesia team, the claim carries the alert "Surgeon Transfer of
Pain Management Not Documented". Ask the practice to document the
surgeon's request.
Pain-round visits are infrequent, and the one-page rounding forms that
carry them lose checkbox marks in text extraction. So by default, every
claim from a packet that contains pain-round content waits for a coder
before it bills. The claim carries the alert "Post-Op Pain Rounds Review
Gate". The autocoder still codes the visit. The coder confirms one of
three outcomes and releases or corrects the claim:
a routine post-anesthesia check, which is not separately billable;
daily management of a neuraxial catheter (01996);
a separately necessary pain visit with a documented surgeon transfer
(hospital E/M).
If your facility trusts the pain-round coding, ask your HANK
representative to turn the gate off, or to narrow it to only the claims
the pain-round lane coded.
Post-Op Pain Rounds Review Gate; Possible Pain-Round Packet Coded as
Surgery; No Billable Pain-Round Service; Pain-Round Date Not Documented;
Pain Rounds on More Than One Day; Surgeon Transfer of Pain Management Not
Documented; Catheter Insertion Date Not Documented; Pain-Round Coverage Is
Payer Variable; Pain-Round Evidence Without a Citation.
The primary-diagnosis alert now reads like a person wrote it. The old
alert said "Primary dx Z12.11 (Encounter for screening for malignant
neoplasm of colon (billable=True)) not attested as reason for procedure.
Validator: src=unattested: return record to provider." The new alert says
where the diagnosis was found in plain words, what to confirm, and what to
do: "Primary diagnosis Z12.11 (Encounter for screening for malignant
neoplasm of colon) is not documented as the reason for this procedure in
the anesthesia record or the procedure note. Where it was found: only the
problem list or past history. Confirm the documentation supports this
diagnosis, or select the diagnosis the record supports. Do not bill from a
problem list or history alone." The alert identifier, severity, and hold
behavior do not change.
The alert fires less often on screening and delivery claims. The
autocoder now reads the pre-anesthesia evaluation and the other anesthesia
record sections when it checks the primary diagnosis, so an indication
documented only on the pre-anesthesia evaluation counts. It also treats the
documented encounter type as the reason for the procedure: "screening
colonoscopy" on the record supports the screening code, and a normal
delivery note supports the delivery code. A procedure with no indication
documented anywhere still routes to a coder.
Cesarean claims keep the documented indication as the primary
diagnosis. The autocoder used to fall back to O82, "cesarean delivery
without indication," whenever a cesarean was performed. Per the FY 2026
ICD-10-CM Official Guidelines, the condition that led to the cesarean is
the principal diagnosis. A repeat cesarean for a prior uterine scar now
bills O34.21- first. O82 appears only when the record documents that there
was no indication.
Separate billing of a postoperative pain injection (62322 family) now
follows the full NCCI conditions. A separate flat-fee line requires all
three: the case ran under general anesthesia, the surgeon's request for
postoperative pain management is documented, and the injection was not the
operative anesthetic. When these are met, the line carries modifier 59 or
XU automatically. When any is missing, the block folds into anesthesia time
and the alert tells the coder exactly how to recover the flat fee: obtain
the surgeon's request, then bill the code with modifier 59 or XU.
Pre-printed form labels are not services. On paper checkbox forms, an
unmarked pre-printed option could be read as a performed service: an
unticked "Labor Epid to C-Section" row became a cesarean, an empty arterial
line grid row became 36620, an empty "E" box became 99140. The autocoder
now requires real documentation: cesarean codes need documented cesarean
anesthesia, a line needs a placement note or a time, and 99140 needs a
documented emergency condition.
If your review workflow matches on the exact text of the primary-diagnosis
alert, update the match: the identifier primary_icd_not_attested is
unchanged, but the description text is new.
