ICD-10 combination codes have always been a conundrum for medical record coders. Vastly different from coding these diagnoses in ICD-9-CM, the guidelines for correct coding of combinations provide coders with more flexibility and decision-making. However, along with greater freedom to assume causal relationships between diseases comes heightened uncertainty.

Four Simple Letters. Big Meaning.

According to the latest correct coding guidelines, if the patient’s diagnosis is documented with another diagnosis, the coder can assume a cause-and-effect relationship. The physician no longer needs to specify the connection. The four-letter word “with” is the trigger. The most common application of this new guideline occurs when coding diabetes mellitus.

Diabetes with Associated Conditions

The new guidance can be found in Coding Clinic First Quarter, 2016. Page 11 addresses the ICD-10-CM Alphabetic Index for “Diabetes with” associated conditions, that are found as a more specific subterm, in the alphabetic index under the term “with”. As stated above, the provider no longer needs to document a relationship between the two conditions. The coder can assume a causal relationship when coding diabetes mellitus and its associated manifestations.
According to the ICD-10-CM Official Guidelines for Coding and Reporting, the term “with” means “associated with” or “due to,” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List, and this is how it’s meant to be interpreted when assigning codes for diabetes with associated manifestations and/or conditions. The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system.
However, if the physician documentation specifies diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication. When the coder is unable to determine whether a condition is related to diabetes mellitus, or the ICD-10-CM classification does not provide coding instruction, it is appropriate to query the physician for clarification so that the appropriate codes may be reported. (See ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.15.)
In ICD-10-CM, coders can now assume a causal relationship between diabetes mellitus and the conditions listed below the subterm “with” if documented in the medical record. This represents a different way of thinking from ICD-9-CM to ICD-10-CM.

Coding example:
Physician documents the following on the H&P: DM, CKD and Foot Ulcer
The following codes would be assigned:
1. E11.22 Diabetes with Chronic Kidney Disease
2. E11.621- Diabetes with Foot Ulcer
Look for the Link

In addition, the following advice published in Coding Clinic Third Quarter 2012, page 3, also applies to ICD-10-CM:
“It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. However, the entire record should be reviewed to determine whether a relationship between the two conditions exists.
The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, query the provider.”

Coders at the Helm

While the new “with” guideline gives coders more autonomy to assume a causal relationship, it also places added pressure on coding teams to be sure clinical documentation supports linkages. When in doubt, always query the provider.

Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS
AHIMA ICD-10-CM/PCS Trainer Certificate Holder
Director of Coding Quality and Professional Development