# Coding clinic clarification on causal conditions



## 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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## CodingKing (Jun 1, 2016)

Nah i think they are wrong. You can't use the with in the index if the documentation doesn't state With/AssociatedWith/Due to. Are you supposed to take it as word from coding clinic email if its not officially published in the Coding Clinic?  There are published coding clinics that state otherwise.

I think they poorly interpreted the ICD-10 general guidelines

I.A.15



> 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 the
> Tabular List.
> 
> ...



There are places in other sections of the ICD-10 Guidelines that state when a causal relationship can be
assumed and diabetes is one of those sections.

Now looking at this.  



> 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."



Dermatitis which is under the With is not a Kidney, Nerve or Circulatory system condition so would also exclude anything else in the E10.6- & E11.6- range which are also under "With"


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## mitchellde (Jun 1, 2016)

This was a letter from Coding Cliniv on their letterhead. They referenced the 2016 coding clinic where it was published do yes I feel this is official advice.  My query to them was in regards to provider documentation not reflecting the relationship. Clearly  from the answer I received, if the alpha listing states "with" and then the condition listed under, we are to assume the relationship and the documentation does not need to reflect this.  The diabetes was only an example provided


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## mommacode (Jun 21, 2016)

I agree, it is clearly stated that "with" means the same as "due to". If diabetes is documented anywhere in the record and one of the conditions listed under "with" is also stated in the record, even though the provider did not link them, the coder is to link them.


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## AllisonDisessa (Jan 29, 2018)

The assumed relationship with the word with is ICD-10 guidelines. ICD-9 you did need to link the diagnosis.


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## okwong (May 3, 2018)

*Clarification*

So I understand that when the word "with" is used in the Alphabetic Index or Tabular list, a causal relationship can be assumed. Does that word "with" have to be used in the provider documentation as well? To my understanding, it does not, that as long as the two conditions are listed in the note, a linkage can automatically be assumed. So a provider can state DM2 and CKD, DM2 with CKD, or even 1. DM 2. CKD 3. neuropathy and the relationship can be assumed. Any feedback would be greatly appreciated!


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## rchojnowski (Jul 2, 2018)

So if the provider documents stasis ulcer, and then lists under comorbidities DM2, are you to link this ulcer to the DM as well as the venous insufficiency?  

Per Dr. Lehrman the "National Pressure Ulcer Advisory Panel provides us with guidance in this area. For ICD-10 purposes, if there is an ulcer on the foot of a diabetic patient, consider it a DFU (and code using “L97-”). This is true even if arterial disease and/or pressure has played a role in its development."

Or, because it is stated to be a stasis ulcer do you code the venous insufficiency and E11.9 for uncomplicated DM2 (along with the ulcer code of course)?


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