Excludes2 relationship
What we found
Yes, when both are documented.Z91.010 carries an Excludes2 note covering Z87.81: “personal history of physical injury and trauma (Z87.81, Z87.82-)”
Excludes2 marks distinct conditions — both may be reported when both are documented.
What to review
Report both only when the documentation supports both conditions; otherwise report the one documented.
Why it matters
An Excludes2 note means the excluded condition is not part of the code above it, but a patient can have both. Report both when both are documented.
Source / rule
CMS ICD-10-CM tabular instructional notes