# Casual relationship between DM and DM compications



## Muthaiya.Murugappan@omegahms.com (May 29, 2016)

Hi all,

           As per ICD 10 cm Is can we assume casual relationship between DM and Dm complication with out linking term? (Except osteomyelitis)
Share your thoughts..


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## achhubhat@yahoo.co.in (May 30, 2016)

*My thoughts*

Yes, except for heart disorders, we can always assume relation between DM & DM complication without linking term


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## Ajesh Kuriakose (May 30, 2016)

*Please refer guidelines section 1.B.9 Combination code guidelines*

Guideline says "Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs" so for diabetes mellitus complications you need the condition to be stated "with /associated with diabetes" or diabetic nephropathy etc. Hope this may be the query you had asked. I couldn't find a guideline like you have stated Achhubhat. Am not much experienced so can't reply based on circumstance, if you are sure of your reply please reply to this thread.


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## mitchellde (May 30, 2016)

achhubhat@yahoo.co.in said:


> Yes, except for heart disorders, we can always assume relation between DM & DM complication without linking term



This is not true, the provider must state a relationship between the diabetes and the complications.  If you have an official reference that states otherwise then I am interested in reading it.


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## terribrown (Jun 1, 2016)

mitchellde said:


> This is not true, the provider must state a relationship between the diabetes and the complications.  If you have an official reference that states otherwise then I am interested in reading it.



AHA Coding Clinic, First Quarter 2016, pages 11-13, ruled that we CAN assume a "cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system." It goes on to state that "if physician documentation specifies diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication."

The "assumed cause-and-effect relationships in the classification are not necessarily the same in ICD-9-CM and ICD-10-CM."

This ruling quotes a previous ruling from "Third Quarter 2012, page 3, that also applies to ICD-10-CM", that states that two conditions do not need to be listed together in the health record...which backs up the causal relationship theory...but it also states that "the fact that a patient has two conditions that commonly occur together does not necessarily mean they are related". This ruling from 2012 also states that "the entire record should be reviewed to determine whether a relationship between two conditions exists." Does this advice give coders the authority to "determine" a causal relationship?? Is this confusion why they came out with the 2016 ruling that INSTRUCTS us to assume a causal relationship?

I can honestly say that I am still confused about this 2016 ruling and would like further discussion/clarification about this NEW theory of DM coding. What say you?


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## mitchellde (Jun 1, 2016)

I questioned Coding Clinics directly regarding clarification on this issue, and just received their response:
"ICD-10 CM presumes a casual relationship between two conditions when they are linked by the term "with" .  The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the alphabetic index, or an instructional note in tabular list."
The example they give then is:

Diabetes, diabetic (mellitus) (sugar) E11.9h
 with
amyotrophy E11.44
arthropathy NEC E11.618
autonomic (poly) E11.43
cataract E11.36
Charcot's joints E11.610
chronic kidney disease E11.22
circulatory complication NEC E11.59
complication E11.8
specified NEC E11.69
dermatitis E11.620
foot ulcer E11.621
gangrene E11.52
gastroparesis E11.43
  And so on
"The sub term "with" in the index should be interpreted as a link between diabetes and any of these conditions indented under the word "with".  The physician documentation does not need to provide a link between  (for example) the diagnoses of diabetes and chronic kidney disease.  This link can be assumed since the chronic kidney disease is listed under the sub term "with".
These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated and due to some other underlying [cause].

So I guess that settles it then? I goes against everything I was taught but there it is.  When I read the instruction regarding the word "with" I still assumed this meant in the documentation, but apparently it was a misinterpretation based on years of training regarding the documentation must link the conditions.


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## terribrown (Jun 1, 2016)

Thank you for following up with AHA to clarify that yes, the assumed causal relationship is there in ICD10 unless stated otherwise. Definitely a new way of coding that will impact Risk Adjustment coding for sure!

Now here are the next questions: 
1. Does that cause-and-effect theory apply to all conditions that contain "with" in the index after the main term? 

2. If yes to #1, and since "with" should be interpreted to mean "associated with" or "due to"...then does this apply not only to the sub-term "with" but also the sub-term "in (due to)"?


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## docmark (Sep 15, 2016)

This update confuses me. How should we code the following scenarios:
1) Dx: DM Type 2
          Foot ulcer, left
          CKD 

as opposed to...

2) Dx: DM Type 2 *with *CKD and foot ulcer, left


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## ancoleman22 (Sep 15, 2016)

Your scenarios would be coded the same way for both situations. You can now assume that the DM is linked to the CKD and the Ulcer since they are linked in the alphabetic index by the word "with" unless stated otherwise by the physician. 

The new guidelines are a bit confusing so I hope I am understanding them correctly! 

We just received our new coding books and looks as if any condition linked in the alphabetic index with the word "with" , you could now assume a relationship such as HTN and heart disease unless stated otherwise. 

Anybody else interrupt the new guidelines as I am?


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## docmark (Sep 16, 2016)

^^^Thank you so much for the clarification.


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## danskangel313 (Sep 16, 2016)

Someone posted a thread elsewhere asking about how to code "Diabetes Type 2 with other circulatory complications" and the patient actively has CAD". Apparently the provider does not document any association or connection of the CAD to the "circulatory complications" or vice versa; as well as no connection of the DM to the CAD and vice versa.

Going off what was posted, it would direct me to "Diabetes with circulatory complications NEC E11.59", but what about the CAD? Before I read this, originally I thought it would be proper to code the DM and the CAD separately, but now I'm incredibly confused. It's the NEC part that confuses me the most, I think. Would it actually be coded as Diabetes with circulatory complications NEC E11.59 and a separate DX for the CAD?

Thoughts?

(As if the DM/CKD/HTN wasn't confusing enough...)


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## Quiet_Mary (Oct 12, 2016)

Wow, I have been using I12.0 all the time (hypertensive CKD with CKD)..... So is it the same concept as with the diabetes?  This IS very confusing.


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## Quiet_Mary (Oct 12, 2016)

*Diabetes Causal Relationship*



mitchellde said:


> I questioned Coding Clinics directly regarding clarification on this issue, and just received their response:
> "ICD-10 CM presumes a casual relationship between two conditions when they are linked by the term "with" .  The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the alphabetic index, or an instructional note in tabular list."
> The example they give then is:
> 
> ...



I use I12.0 all the time with Hypertension and CKD, so I'm assuming that it's the same concept for that as well???


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## anne32 (Oct 26, 2016)

so just to make sure I'm understanding this correctly... Let's say a chart shows the patient has DM Type II and then later on in the note separately it shows the patient has a foot ulcer. Since the patient has both conditions in the chart, we would code this as E11.621 and then a secondary code for the stage. Is this correct? Or does the documentation need to say DMII WITH Foot ulcer?


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## mitchellde (Oct 26, 2016)

anne32 said:


> so just to make sure I'm understanding this correctly... Let's say a chart shows the patient has DM Type II and then later on in the note separately it shows the patient has a foot ulcer. Since the patient has both conditions in the chart, we would code this as E11.621 and then a secondary code for the stage. Is this correct? Or does the documentation need to say DMII WITH Foot ulcer?



you are correct,  Under ICD-10 CM structure this would be coded as a diabetic foot ulcer without the provider needing to state the relationship.


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## anne32 (Oct 27, 2016)

I've come across another chart where the patient has DMII and cellulitis. Would I code E11.628- DMII with other skin complications and then code the cellulitis. Or would I just code E11.9 (assuming it's controlled) and then the cellulitis?


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## dslattery (Nov 18, 2016)

*Diabetes assumption*

We had a webinar on this last week and I'm still having trouble wrapping my head around changing all my current patients with HTN with CKD and diabetes and making the link with the CKD and diabetes even though the hospital states that it's due to HTN. We have patients that have been on our service for years so adding E11.22 now just doesn't feel right since the MD and the hospital only list the CKD with HTN. Is anyone else seeing that the hospitals are not making that DM link with CKD if the patient has HTN too? I'm assuming the HTN with CKD but adding the E11.22 is perplexing for me to assume all three are related. Is everyone coding it that way?


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## sgregoire (Dec 24, 2016)

*Cpc*



mitchellde said:


> This is not true, the provider must state a relationship between the diabetes and the complications.  If you have an official reference that states otherwise then I am interested in reading it.



For outpatient coding, I believe you will find your answer in the NEW 2017  ICD10 Guidelines.  Unfortunately, those guidelines were not added to the new books.  See page 1 of the guidelines in the 2017 ICD10 books.At the very top it reads the guidelines are 2016.  You can find the correct guidelines on the CMS website. And you can order them also from that site.


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## sgregoire (Dec 24, 2016)

ancoleman22 said:


> Your scenarios would be coded the same way for both situations. You can now assume that the DM is linked to the CKD and the Ulcer since they are linked in the alphabetic index by the word "with" unless stated otherwise by the physician.
> 
> The new guidelines are a bit confusing so I hope I am understanding them correctly!
> 
> ...



I would add that the category, I11 "Hypertensive heart disease INCLUDES any condition I51.4 - I51.9 due to hypertension.  There are only two codes, I11.0 Hypertensive heart disease with heart failure and I11.9 Hypertensive heart disease without heart failure."  With heart failure, requires the I50.4 - I50.9 code. Must be heart failure.


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