Ob-Gyn Coding Alert

Hint: Don’t look for ‘with’ in the alphabetic index.

If there’s one generalization people could make about the human body and medicine: it’s complicated. The ICD-10-CM code set catalogues many conditions that are related to other conditions, and guidelines to help coders and other stakeholders navigate reporting.

Specifically, guideline I.A.15 in the ICD-10-CM Official Guidelines provides instructions on how to report multiple conditions together.

Don’t get tripped up when you encounter “with” in a guideline; use these helpful tips.

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

If the provider records a relationship between two conditions, you should code them as related. For instance, suppose a provider indicates a patient’s obstructed labor (at term) and her cervical benign tumor found four months ago are related. You’ll use O65.5 (Obstructed labor due to abnormality of maternal pelvic organs) to report that the obstructed labor is associated with the tumor. However, O65.5 features a Code also note that requires you to assign the appropriate codes for the cervical anomaly. In this case, the code will be O34.43 (Maternal care for other abnormalities of cervix, third trimester).

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.

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

Don’t Go Overboard With Reporting

Scenario: A pregnant patient who has a positive pregnancy test result performed by her PCP presents to your office for her first prenatal visit. An ultrasound is done to date the pregnancy, which shows the placenta with an empty embryonic sac. The patient is less than 20 completed weeks gestation, and the provider diagnoses missed abortion with blighted ovum.

In this scenario, some providers may select O02.1 (Missed abortion) and O02.0 (Blighted ovum and nonhydatidiform mole) in their electronic health record (EHR), but that is incorrect. This is because the code O02.1 has an Excludes1 Note that directs you to report only O02.0 for cases of missed abortion with blighted ovum. Therefore, only one code is required to indicate a “with” condition and satisfies the patient’s diagnosis.

By using the “with” guideline, you can code the scenario’s conditions correctly much of the time. While the first codes of O20.1 and O20.0 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 the scenario above, 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 codes to match your provider’s documentation.

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 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.