Wiki DM with HTN

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I agree with @thomas7331 on this one, and To help explain the "with" and causal link I got this nifty reference to explain a little further:

AHA CODING CLINIC

Volume 3 – Number 2 Second Quarter 2016

Clarification

Diabetes and Associated Conditions ​

The AHA Central Office has received several questions requesting clarification of the advice published in the First Quarter 2016 issue regarding diabetes and associated conditions. The published advice is based on Guideline Section I.A.15 which says: “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. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular.

The following example from the Alphabetic Index for the main term “Diabetes” and the subterm “with” demonstrates this linkage:

Diabetes, diabetic (mellitus) (sugar) E11.9 with

Amyotrophy E11.44

Arthropathy NEC E11.618

Autonomic (poly) neuropathy E11.43

Cataract E11.36

Charcot’s joints E11.610

Chronic kidney disease E11.22

The subterm “with” in the Index should be interpreted as a link between diabetes and any of those conditions indented under the word “with.” The physician documentation does not need to provide a link between the diagnoses of diabetes and chronic kidney disease to accurately assign code E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease. This link can be assumed since the chronic kidney disease is listed under the subterm “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 besides diabetes. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.” [emphasis added].
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Since DM and HTN are not specifically called out in the Index of any ICD-10 book I have seen, I would recommend we exercise caution when trying to create a causal link between DM and HTN. As the Coding Clinic above me explains, if the provider doesn't specifically make the linkage between DM and HTN, we should not create a causal link between them as they are not part of that rule/guideline.

Unless there is a more current Coding Clinic or direct official rule, then I would not make that causal linkage as explained above.

Hope this helps! If not, ask! :)
 
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Pathos said:
I agree with @thomas7331 on this one, and I got this nifty reference to explain a little further:



Since DM and HTN are not specifically called out in the Index of any ICD-10 book I have seen, I would recommend we exercise caution when trying to create a causal link between DM and HTN. As the Coding Clinic above me explains, if the provider doesn't specifically make the linkage between DM and HTN, we should not create a causal link between them as they are not part of that rule/guideline.

Unless there is a more current Coding Clinic or direct official rule, then I would not make that causal linkage as explained above.

Hope this helps! If not, ask! :)
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This is nifty information! I love it.

I do have a question.... In the original post, [U]megha80p@hotmail.com[/U] states: "How would you code if provider documents "DM with HTN"?"

Thomas7331 responded with: "Hypertension is not linked with diabetes in the ICD-10 Alphabetic Index or Tabular List, so you cannot presume a causal relationship unless documented."

While his statement is correct, I also thought it was E11.59, I10 (as Taysin93 says) since the word used was "with".
I guess my confusion would be- isn't the provider linking DM with HTN when he or she stated "DM with HTN"?
I would think it would not link if the word was "and", but she states "with".

Just trying to get clarification. :) I am looking to fine tune my risk skills and stumbled across this post!
 
nrood said:
This is nifty information! I love it.

I do have a question.... In the original post, [U]megha80p@hotmail.com[/U] states: "How would you code if provider documents "DM with HTN"?"

Thomas7331 responded with: "Hypertension is not linked with diabetes in the ICD-10 Alphabetic Index or Tabular List, so you cannot presume a causal relationship unless documented."

While his statement is correct, I also thought it was E11.59, I10 (as Taysin93 says) since the word used was "with".
I guess my confusion would be- isn't the provider linking DM with HTN when he or she stated "DM with HTN"?
I would think it would not link if the word was "and", but she states "with".

Just trying to get clarification. :) I am looking to fine tune my risk skills and stumbled across this post!
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Per the ICD-10 guidelines under I.A.15: "'with' or 'in' should be interpreted to mean 'associated with' or 'due to' when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List."

So the causal relationship is only presumed when we see 'with' in ICD-10 - it is not presumed when the provider documents the word 'with'.
 
thomas7331 said:
Per the ICD-10 guidelines under I.A.15: "'with' or 'in' should be interpreted to mean 'associated with' or 'due to' when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List."

So the causal relationship is only presumed when we see 'with' in ICD-10 - it is not presumed when the provider documents the word 'with'.
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If I am on base now- you would be looking for the provider to say something like: "diabetes related hypertension".
One should not assume that because the provider states "DM with HTN" that they are linking the two, as a casual relationship is only presumed when "with" is listed in ICD-10. (Sound right?)
 
nrood said:
If I am on base now- you would be looking for the provider to say something like: "diabetes related hypertension".
One should not assume that because the provider states "DM with HTN" that they are linking the two, as a casual relationship is only presumed when "with" is listed in ICD-10. (Sound right?)
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Correct, the conditions listed in ICD-10 that are connected by 'with' or 'in' are conditions that are very commonly related, so should be assumed and coded as related even if the provider has not stated it. If you don't find the 'with' or 'in' relationship in the coding guidelines, then you assume that they are not related unless the provider has documented that there is a relationship. In physician documentation you'll find this relationship stated as 'due to' or 'secondary to'.

In my years of coding, I have never seen a provider indicate that hypertension was caused by diabetes, or vice versa, and I've never heard that diabetes ever does actually cause hypertension, even though the two diseases are often found in the same patient. Diabetes commonly causes diseases of the kidneys and eyes, peripheral neuropathy and angiopathy, and foot ulcers, etc. Hypertension commonly causes kidney disease and some forms of heart disease. So these (and a few others) are the relationships that are linked in ICD-10 which you can code as related even without provider documentation explicitly stating the relationship.
 
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At the end of the day, the decision to pick up/not to pick up an HCC lies within your organization. Yes, we should follow the guidelines set forth by the ICD-10 book, along with the Coding Clinics, however there are so many gray areas (some done on purpose). I would caution to lean too much into clinical information, even if medically the documentation doesn't always make sense. Diabetes can have a myriad of complications, and if the provider connects the two conditions together, then I believe we as coders have an obligation to pick them both up (as long as they still have MEAT). (I updated my previous response above).
 
Can i piggy back on this, as i am trying to make sure i understand it as well. I have providers for HCC purpose who document " associated with ". I seen providers who will say “DM associated w/HTN" or the reverse “HTN associated with DM". per the book, i realized

under HTN, you look under “ with “ there is no DM, but if you go under “ due to” there is no DM but there is endocrine disorder I15.2, DM falls under endocrine disorder

under DM, you look under “ with “ there is no HTN, closes would be circulatory complication, because HTN is a circulatory complication E11.59.

is it fair to say it all depends how the provider documents it because it does make a difference in diagnosis coding??
 
KoBee said:
Can i piggy back on this, as i am trying to make sure i understand it as well. I have providers for HCC purpose who document " associated with ". I seen providers who will say “DM associated w/HTN" or the reverse “HTN associated with DM". per the book, i realized

under HTN, you look under “ with “ there is no DM, but if you go under “ due to” there is no DM but there is endocrine disorder I15.2, DM falls under endocrine disorder

under DM, you look under “ with “ there is no HTN, closes would be circulatory complication, because HTN is a circulatory complication E11.59.

is it fair to say it all depends how the provider documents it because it does make a difference in diagnosis coding??
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Personally, I would not interpret the language 'associated with' to imply a causal relationship. When I've seen 'associated with' in documentation, it means 'occurring together with' or 'complicated by'. To code for a causal relationship in situations where ICD-10 does not presume the relationship, I would look for terms such as 'caused by', 'due to', 'secondary to', 'resulting from', etc. But your employer or quality/audit team may have more specific guidance for you on this.

So yes, it does depend on how the providers documents, and of course the guidelines direct you to query the provider when the documentation is unclear or has conflicting information.
 
thomas7331 said:
Personally, I would not interpret the language 'associated with' to imply a causal relationship. When I've seen 'associated with' in documentation, it means 'occurring together with' or 'complicated by'. To code for a causal relationship in situations where ICD-10 does not presume the relationship, I would look for terms such as 'caused by', 'due to', 'secondary to', 'resulting from', etc. But your employer or quality/audit team may have more specific guidance for you on this.

So yes, it does depend on how the providers documents, and of course the guidelines direct you to query the provider when the documentation is unclear or has conflicting information.
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What circulatory complications NEC qualify for E11.59? Some auditing contractors argue that Hypertension does have a causal relationship due to the impact Diabetes has on the cardiovascular system
 
Ryverja1 said:
What circulatory complications NEC qualify for E11.59? Some auditing contractors argue that Hypertension does have a causal relationship due to the impact Diabetes has on the cardiovascular system
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The only complications that can be coded to E11.59 are 1) those that are linked to that code through the ICD-10, if any; or 2) those that are linked through a causal relationship documented by the provider in the patient's record.

If you have an auditor that is making the argument that there is a causal relationship that warrants the use of E11.59, then they should be able to point to either the place in ICD-10 that directs to that code, or to the language in the provider's documentation that supports the use of that code. The auditor may be correct that there is a causal relationship, but they still have to adhere to the guidelines when it comes to code assignment.
 
thomas7331 said:
Correct, the conditions listed in ICD-10 that are connected by 'with' or 'in' are conditions that are very commonly related, so should be assumed and coded as related even if the provider has not stated it. If you don't find the 'with' or 'in' relationship in the coding guidelines, then you assume that they are not related unless the provider has documented that there is a relationship. In physician documentation you'll find this relationship stated as 'due to' or 'secondary to'.

In my years of coding, I have never seen a provider indicate that hypertension was caused by diabetes, or vice versa, and I've never heard that diabetes ever does actually cause hypertension, even though the two diseases are often found in the same patient. Diabetes commonly causes diseases of the kidneys and eyes, peripheral neuropathy and angiopathy, and foot ulcers, etc. Hypertension commonly causes kidney disease and some forms of heart disease. So these (and a few others) are the relationships that are linked in ICD-10 which you can code as related even without provider documentation explicitly stating the relationship.
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i am a nurse with years of experience and i can tell you with certainty that elevated bp is closely related to diabetes. a person with diabetes and HTN is four ltimes as likely to develop heart disease than soemone who does not have either condtiion. The coexistence of diabetes and hypertension is known to have a multiplicative effect on adverse clinical outcomes with respect to both microvascular and macrovascular disease. Effective management of diabetes should therefore include a multifaceted approach combining optimal control of blood pressure and lipids with appropriate glycemic control (national libary of medicine).

HTN will be considered a circulatory complication - threfore, E11.59 DM with circulatory complications would be the diagnosis code to be assigned as long as the provider includes "clear, concise and non contradictory" documentation that hypertension is due to diabetes or that the patient suffers from "diabetic hypertension". I have seen some articles that suggest to code I15.2, hypertension related to endocrine disorders.. but personally i haven't seen this code being added.

In regards to dx code E11.69 - type 2 diabetes mellitus with OTHER specfided complications . Let's review codes title "other" or "other specifided" - these codes are used when the information in the medical records provides detail for which a specific code does not exist .. therefore, this code will apply if the "other specified " complication does not exist as a code in icd10 clasification - BUT in this case a code DOES exist - so, a more specific code to indicate diabetes has a circulatory complication will be E11.59 .. and which one is the complication = I10
 
hello,
in AAPC January 2024 quiz, there is a question on how to code E11.9 and hypertension. And the answer was to code them as linked E11.59 and i10 "because i10 relates to circulatory system." Nothing was mentioned of the Index that does not link them together. I agree with Thomas7331. I read the answers in this forum and they are different. I know I should use the guidance of the Quiz but somehow I am not convinced in it. I just would like to bring this topic again and I wonder if it was an error in the quiz and we should contact AAPC?
Undecided coder.
 
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megha80p@hotmail.com said:
Hi,

How would you code if provider documents "DM with HTN"? Do you code E1159/E1169 and I152?
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I agree, only code E11.9 and I10. The provider does not need to document the relationship between these manifestations when they are described using the word “with” and they may be assumed to be related, unless the provider states they are not related.
 
cathtech said:
I agree, only code E11.9 and I10. The provider does not need to document the relationship between these manifestations when they are described using the word “with” and they may be assumed to be related, unless the provider states they are not related.
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I e-mailed AAPC yesterday about this question and they responded today stating that the relationship between hypertension and diabetes CAN NOT be assumed and that they are correcting the question on the January 2024 magazine quiz.
 
Hello everyone,


Diabetes is a multifactorial disease. DM pathophysiology involves not only the pancreas but it also includes the liver, skeletal muscle, adipose tissue (a connective tissue composed of fat cells that store energy, regulate metabolism, and insulate the body), GI tract, brain and of course the kidneys. Also consider how DM damages arteries by making them targets for hardening -this we know it as atherosclerosis which in return cause HTN.
ultimately, most pt's with diabetes will eventually have hypertension and HTN is a circulation complications.

1724889078930.png

pathophysiology - the study of disordered physiological processes related to disease or injury
 
jdecelleri said:
Hello everyone,


Diabetes is a multifactorial disease. DM pathophysiology involves not only the pancreas but it also includes the liver, skeletal muscle, adipose tissue (a connective tissue composed of fat cells that store energy, regulate metabolism, and insulate the body), GI tract, brain and of course the kidneys. Also consider how DM damages arteries by making them targets for hardening -this we know it as atherosclerosis which in return cause HTN.
ultimately, most pt's with diabetes will eventually have hypertension and HTN is a circulation complications.

View attachment 7295

pathophysiology - the study of disordered physiological processes related to disease or injury
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So which is the correct answer: E11.9 and I10 or E11.59 and I10----see below:

jtmoore93​

New​


cathtech said:
I agree, only code E11.9 and I10. The provider does not need to document the relationship between these manifestations when they are described using the word “with” and they may be assumed to be related, unless the provider states they are not related.
Click to expand...
I e-mailed AAPC yesterday about this question and they responded today stating that the relationship between hypertension and diabetes CAN NOT be assumed and that they are correcting the question on the January 2024 magazine quiz.
 
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