ICD 10 Coding Alert

Back to Basics:

Leave Your ‘With’ Guideline Misunderstandings Behind

Published on Wed Nov 02, 2022

Hint: Don’t look for ‘with’ in the alphabetic index.

If there’s one generalization people could make about the human body and medicine: it’s complicated. The ICD-10-CM code set catalogues many conditions that are related to other conditions, and guidelines to help coders and other stakeholders navigate reporting. Specifically, guideline I.A.15 in the ICD-10-CM Official Guidelines provides instructions on how to report multiple conditions together.

Don’t get tripped up when you encounter “with” in a guideline; use these helpful tips.

Define ‘With’ Per ICD-10-CM

When you encounter “with” or “in” in a code title (descriptor), the Alphabetic Index, or an instructional note in the tabular list, you’ll treat “with” or “in” as “associated with” or “due to.” As a result, “the classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or tabular list,” according to the guideline.

Other terms used in provider documentation showing a link between two conditions may include:

As a result of
Caused by
Complicated by
Resulting in

If the provider records a relationship between two conditions, you should code them as related. For instance, suppose a provider indicates a patient’s chronic obstructive pulmonary disease (COPD) and acute bronchitis are related. You’ll use J44.0 (Chronic obstructive pulmonary disease with (acute) lower respiratory infection) to report the COPD that is associated with bronchitis. However, J44.0 features a Code also note that requires you to assign the appropriate code for the infection, if known. In this case, the infection code is J20.9 (Acute bronchitis, unspecified).

Note: The word “with” is listed immediately after the main term or subterm in the Alphabetic Index, instead of in alphabetical order. This allows you to locate the related condition quicker than having to search through the subterms.

Coders may wonder if the provider’s documentation needs to explicitly link two or more conditions together. “The guidelines also tell us that these conditions need to be coded as related, even in the absence of provider documentation explicitly linking them. So, the provider doesn’t have to say that the conditions are related for us to grab the code. Unless that provider says that the condition is unrelated,” said Kate Tierney, CPC-I, CPMA, CPC, CPC-P, CRC, COBGC, CGSC, CEMC, CEDC, CBCS, CMAA, CICS, CHI, CEHRS, CPhT, during the “Do You Really Understand the ‘With’ Guideline?” session at AAPC’s HEALTHCON 2022 conference.

Note these exceptions: One exception to the guideline occurs when your provider states the conditions are unrelated. Another exception is when another guideline exists that specifically requires a documented linkage between two conditions.

In these situations, make sure you review the documentation before assigning codes to determine if two conditions are related. There are times when a patient has two conditions that commonly occur simultaneously, but that doesn’t necessarily mean they are related for the current encounter. In those circumstances, you’ll assign two separate codes instead of a combination “with” code.

Don’t Go Overboard With Reporting

Scenario: A patient presents to a pulmonology practice with fever, dry cough, sore throat, headache, and muscle pain. The pulmonologist orders chest X-rays, which confirm acute pneumonia. The patient also tests positive for the flu. The provider determines the patient’s flu infection is causing the pneumonia. The patient’s diagnosis is pneumonia with influenza.

In this scenario, some providers may select J18.9 (Pneumonia, unspecified organism) and J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations) in their electronic health record (EHR), but that is incorrect. When you look up Pneumonia (acute) in the ICD-10-CM Alphabetic Index, you can follow the indentations to with > influenza where you’ll be directed to look up Influenza, with, pneumonia. Turning to Influenza > with > pneumonia, you’ll arrive at J11.00 (Influenza due to unidentified influenza virus with unspecified type of pneumonia), which you can verify in the tabular list. This code features an additional synonym of Influenza with pneumonia NOS, which satisfies the patient’s diagnosis.

By using the “with” guideline, you can code the scenario’s conditions correctly. While the first codes of J18.9 and J11.1 may reflect the patient’s diagnosed conditions, using the codes isn’t following proper coding guidelines and instructions. Sometimes, using two codes for two diagnoses is correct, but in other instances, such as the scenario above, you only need one code to report the diagnoses. Staying aware of the ICD-10-CM coding guidelines and paying attention to instructions in the tabular list allow you to use the correct codes to match your provider’s documentation.

Pocket These Helpful Tips

Look at the Alphabetic Index and you’ll find many conditions featuring a “with” indication. An easy way to know when a condition features a “with” indication is to grab a highlighter and mark the instances in your book. “Go into the codes you use most often and highlight that ‘with’ in your book, in your eBook; or your cheat sheet should have a list. If the patient has hypertension, there’s ‘with’ guidelines, or if they have those common conditions that you see, go back and double-check,” Tierney adds.

To help providers remember to document related conditions, you can reach out to and work with your EHR vendor. “Make sure those related conditions, the ones that need a combination code, populate correctly,” Tierney says. When the EHR system is updated, share that information with your providers, so “that the EHR is helping them figure out when to use the combination codes,” Tierney adds. Plus, by reporting one correct code instead of two separate codes that may be incorrect, the providers will have accurate information for risk adjustment scores and quality measures.