Mind Manifestation in This Myelodysplastic Syndrome Situation
Question: The provider documented myelodysplastic syndrome (MDS) and pancytopenia. Under myelodysplastic syndrome in the ICD-10-CM Alphabetic Index there is an entry for “with, pancytopenia.” However, there is no entry for pancytopenia under syndrome, myelodysplastic. Should this be coded as D46.Z or would D46.9 and D61.818 be more correct? AAPC Forum Participant Answer: D46.Z (Other myelodysplastic syndromes) is not the correct way to code these conditions. Instead, your second choice, coding D46.9 (Myelodysplastic syndrome, unspecified) along with D61.818 (Other pancytopenia) would be more correct. There are two reasons why. First, D46.Z implies that the provider has specified a type of MDS other than the specified types of MDSs listed under parent code D46.- (Myelodysplastic syndromes), which your note does not indicate. That makes the unspecified code D46.9 more appropriate than the “other” code, D46.Z, in these circumstances. Second, ICD-10-CM guideline I.B.15 provides guidance on how to code conditions classified as syndromes, telling you to “Follow the Alphabetic Index guidance when coding syndromes” and to “assign codes for the documented manifestations of the syndrome.” Given that pancytopenia is listed in the Alphabetic Index as a manifestation; that guideline I.A.15 tells you “The word ‘with’ or ‘in’ should be interpreted to mean ‘associated with’ or ‘due to’”; and the “Conditions should be coded as related even in the absence of provider documentation explicitly linking them,” you should consider “with” a “Use additional code” instruction. The fact that pancytopenia (due to) (with) myelodysplastic syndromes (D46.-) is listed as an Excludes2 instruction for D61.818 (Other pancytopenia) adds further justification for using two codes in this situation, as this indicates the two codes can be used together per ICD-10-CM. For this encounter, then, you should use both D46.9 and D61.818. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC 
