Don’t miss exclusions: Capture them cleanly Appropriate exclusions help ensure patients are counted accurately. When an exclusion applies, ensure it is clearly documented in the medical record and refected in the claim/encounter pathway so measurement aligns with clinical reality. Common ICD-10-CM examples for exclusions (not all-inclusive; subject to change): Tip: Use diagnosis codes on the claim/encounter when an exclusion applies; some exclusions may also be captured via paid pharmacy claims where applicable. Measure Exclusion Common ICD-10-CM code examples
SUPD
Rhabdomyolysis/Myopathy/Myositis
G72.0, G72.89, G72.9, M60.80, M60.819, M60.829, M60.839, M60.849, M60.859, M60.869, M60.879, M60.9, M62.82 K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69
SUPD
Cirrhosis
SUPD SUPD SUPD
Pre-diabetes
R73.03, R73.09
Polycystic ovary syndrome (PCOS) End-stage renal disease (ESRD)
E28.2
I12.0, I13.11, I13.2, N18.5, N18.6, N19, Z91.15, Z99.2
SPC-E
Myalgia/Myopathy/Myositis/ Rhabdomyolysis
M79.1, M79.10, M79.12, M79.18, G72.0, G72.2, G72.9, M60.80, M60.811, M60.812, M60.819, M60.821, M60.822, M60.829, M60.831, M60.832, M60.839, M60.841, M60.842, M60.849, M60.851, M60.852, M60.859, M60.861, M60.862, M60.869, M60.871, M60.872, M60.879, M60.88, M60.89, M60.9, M62.82 K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69, P78.81
SPC-E
Cirrhosis
SPC-E SPC-E
ESRD (examples)
N18.5, N18.6, Z99.2
Palliative care (encounter) Z51.5 Top 5 Reminders — SPC-E / SUPD Adherence Season
1. Start early. Lost adherence days can’t be “made up” later. 2. Make sure flls count: Pharmacy claims should run through the patient’s health plan insurance; cash pay, samples, and out-of-network flls don’t count for adherence measures. 3. Avoid samples for statins when adherence is being measured. Samples can negatively impact measurement. 4. Use refll supports (when appropriate): Auto-refll, mail order, and extended days’ supply can help reduce gaps. 5. Document exclusions when they apply and code them appropriately (see common ICD-10 examples above) so persons are counted appropriately. Spring 2026 Fidelis Care Provider Bulletin pg. 4
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