Guideline I.A.15 “With”
The FY 2017 updates introduced a major change to Guideline I.A.15 “With” as depicted in bold print below:
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 List. 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. 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.
As clearly stated above the exception to the rule when assuming a cause and effect relationship is when the provider documents that the two conditions are unrelated and due to some other underlying cause. This is supported by several Coding Clinic references including:
- First Quarter 2016 P. 11
- Second Quarter 2016 P. 36
The FY 2018 updates introduced another change to this guideline and again the revisions appear in bold type:
The word “with” or “in” 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 List. 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 or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).
For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.
This revision clarified an additional criterion that supersedes the assumption of cause and effect between two conditions – when another official guideline states that the relationship between the two conditions must be specifically documented by the provider. Again this is supported by several Coding Clinic references including:
- Fourth Quarter 2017 P. 98
- Fourth Quarter 2017 P.99
There is a third situation where recent Coding Clinic advice is setting anther precedence that precludes the assumption of a cause and effect relationship. The “with” guideline does not apply to “not elsewhere classified (NEC)” index entries because these codes cover broad categories of conditions. The following Coding Clinic references provide this advice:
Fourth Quarter 2017 P. 100 & 101
Second Quarter 2018 P. 6
Although this particular exception has not been incorporated into the official guidelines coders should be applying this exception consistently when reporting NEC codes under the subterm “with” for the mainterm Diabetes and any other conditions. For example the listing below shows all of the NEC codes under the mainterm Diabetes and the subterm “with”:
Diabetes, diabetic (mellitus) (sugar) E11.9
- with
- arthropathy NEC E11.618
- circulatory complication NEC E11.59
- complication E11.8
- specified NEC E11.69
- kidney complications NEC E11.29
- neurologic complication NEC E11.49
- ophthalmic complication NEC E11.39
- oral complication NEC E11.638