Wiki Documented support for dx

[KShan]

Hello- I was taught in my first Risk Coding position not to use the word "with" in provider documentation to establish support or causal relationship. (I get that it is used in the tabular to mean "due to", etc). Does this sound familiar to anyone else, and if so- do you know of a source I can site that supports this practice?

 

[natashalage]

Hello, I am not an expert but per Official coding guidance, the word 'with' means "due to", related= presents a linkage between 2 documented conditions; therefore, we use it, the word 'with' is important. For example, MD documents 'diabetes with hyperglycemia", these 2 conditions are connected and the Index directs you to the correct code E11.65. Diabetes with cataract= E11.- there is one code.