New coding guidance on “with” changes how coders link diagnoses

art for monday fix may 16Editor’s note: This post appeared in the May 16 issue of “The Monday Fix,” a weekly email from HHS featuring coding tips.  Click here if you’d like to subscribe. 

It may be time to rethink the way you’re coding some stated and assumed relationships in light of new Coding Clinic guidance.

Two back-to-back articles released last week by AHIMA proved to be an eye-opener for many home health coders, updating and replacing previous information about cause-and-effect coding practices.
A Code Cracker Blog post on the Journal of AHIMA website and an article in the May issue of Codewrite, AHIMA’s e-newsletter, both referenced new Coding Clinic advice that reverses much of the thinking among home health coders on the use of subterm conditions listed next to primary diagnoses under the category “with.”

The articles acknowledged Coding Clinic advice that the word “with” should be interpreted to mean a cause-and-effect relationship if:
1.The patient has both diagnoses confirmed by the physician, and
2.There is no other cause provided for the subterm condition.

Examples were offered by AHIMA for a diagnosis of diabetes mellitus, which has some 53 conditions listed under the subterm “with” in ICD-10 coding manuals.
Those conditions may now be coded as complications of diabetes mellitus if the documentation supports both and if no other cause is given.
This means, for example, that coders may accurately assign the code E11.22 (for Type 2 Diabetes with Chronic Kidney Disease) if the physician has separately documented that the patient has both DM and CKD. There is an assumed relationship because CKD appears in the list of conditions associated with DM.
And the new interpretation does not apply only to diabetis mellitus and its 53 subterm conditions; it applies to any diagnosis where the word “with” appears above a list of related conditions.
The one noteable exception is hypertension with heart disease.
For many coders, especially those who trained under a different ICD-9 interpretation, the cause-and-effect assumption will prompt a major shift in thinking.
“Anytime we see the word ‘with’ underneath a diagnosis — except hypertension with heart disease — we are now to assume a cause-and-effect relationship unless the physician indicates another cause,’’ explains Kimberly Searcy, Director of Global Education for Home Health Solutions.
Kimberly joined a group of home health coding professionals for advanced coding training in Houston last week, as the home health coding field was abuzz with questions about the new interpretation, wondering exactly how it will affect their coding.
“This confirmation changed the way we have been coding since the beginning,” Kimberly says. “Coding Clinic states they clarified the original guidance in 2009 when the original update to the coding convention was made. Their clarification, however, was never read the way it was intended.”
Instead, home health coders divided into two camps on the issue. In one camp, many coders assumed it was necessary for documentation from the physician to link the main term listed and any condition under the subterm “with,” while the other camp believed the link was not necessary.

Coding Guidelines:
Here’s what the ICD-10-CM Official Guidelines for Coding and Reporting actually states at 1.A.15:
“The word ‘with’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetical Index, or an instructional note in the Tabular List.
“The word ‘with’ in the Alphabetical Index is sequenced immediately following the main term, not in alphabetical order.”

How will this new interpretation apply to you?

If you have been interpreting the guideline incorrectly, in most cases you will simply need to begin applying the clarified interpretation to your current charts, going forward, without correcting any previous charts. Please check with your employer, however, to confirm that you will not need to update any previous charts.

If you are uncertain about whether documentation supports an association between a diagnosis and conditions due to its complications, it is best to send a query to the physician requesting clarification.

“Updated confirmation will be in print form for release in second quarter, but we are to begin now according to the article released by AHIMA,” Kimberly says. “Coding Clinic has given verbal confirmation along with AHIMA.”

She also offers this bit of sound advice to home health coders about the latest change:
“Don’t get too complacent. Be willing to roll with the changes in ICD-10, which are always on the horizon!”

Here’s a case example:

Marti Holthus, a Quality Reviewer and Mentor for Home Health Solutions, provides this example of how the new interpretation might apply in a coding scenario where stated and assumed relationships must be considered:    Your patient has insulin dependent diabetes, hypertensive heart disease, end stage renal disease, and acute on chronic systolic and diastolic congestive heart failure. He goes to the dialysis center 3 times per week. Skilled nursing is ordered for CHF monitoring and teaching.How do you code this scenario when there are assumed and stated relationships between the diagnoses?Assumed Relationships:
You may assume a relationship between hypertension and chronic kidney disease. Per updated guidance from the Coding Clinic, you may also presume a cause-and- effect relationship between diabetes and CKD/ESRD unless the physician indicates another cause. If the patient has hypertensive heart disease, you must select a code for with or without heart failure.Stated Relationships:
As of right now, we may not assume a relationship between hypertension and heart disease. The physician must state the heart disease is due to hypertension or it may be implied (hypertensive).

Focus of Care:
The focus of care in this scenario is the exacerbated heart failure; however, this diagnosis cannot be coded first due to sequencing instructions.

Begin your search by looking in the index under hypertension. Notice that hypertensive heart disease with CKD is listed in the index under hypertension, cardiorenal disease.
From there you must choose between with heart failure or without heart failure. I13.2 is coded because the patient has heart failure and ESRD.
Next locate the code for diabetes with chronic kidney disease E11.22 which must also precede the end stage renal disease code per coding instructions.

The correct coding would be:
Hypertensive heart and chronic kidney disease with heart failure and with ESRD I13.2
Acute on chronic combined CHF I50.43
Diabetes with chronic kidney disease E11.22
End stage renal disease N18.6
Dialysis status Z99.2
Long term insulin use Z79.4

Note that if the focus of care had been diabetes rather than exacerbated heart failure, E11.22 would be listed first, followed by hypertensive heart disease, heart failure, and end stage renal disease.