Pathology/Lab Coding Alert

Don’t miss guideline instructions for two conditions.

When it comes to diagnosis coding, labs and pathologists have different roles — but coders for both specialties need to understand ICD-10-CM guidelines and how coding can impact coverage.

One rule in particular impacts how to report multiple conditions: guideline I.A.15 in the ICD-10-CM Official Guidelines. At the center of the guidance is what to do when you encounter the word “with” in ICD-10-CM. Read on to help you navigate this guidance.

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

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.

If the provider records a relationship between two conditions, you should code them as related.

But 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 to the current encounter. In those circumstances, you’ll assign two separate codes instead of a combination “with” code.

Don’t Go Overboard With Reporting

When a combination code is available for two associated conditions, you should use that code instead of reporting the code for each condition using two ICD-10-CM codes.

For instance: The pathologist examines a bone specimen from a female patient’s right femur and diagnoses a pathologic fracture. The op report states that the patient has postmenopausal osteoporosis.

Wrong: You should not report the case as 733.01 (Senile osteoporosis) and M84.451 (Pathological fracture, right femur).

By using the “with” guideline, you can code the scenario’s conditions correctly much of the time. While 733.01 and M84.451 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 this scenario, 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 combination code for this case, which is M80.051A (Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture).

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 obstructed labor, 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 electronic health record (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.