Question CKD and Diabetes

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3
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I have a question regarding CKD and Diabetes. I know with Risk Adjustment Coding there is an assumed relationship between CKD and Diabetes and also CKD and Hypertension but if the doctor
only states in the HPI CKD, DM, HTN do I assume the relationship or does the word "with" need to be stated also. Example : HPI states 91 year male with history of CKD, COPD, Anemia, DM, HTN admitted
with SOB. Do I code the DM and HTN ??? I looked back in my CRC book and it states the provider does not need to document the the relationship between these manifestations when they are described
using the word "with" , they may be assumed to be related unless the provider states they are not related. I am going back an forth with my co workers regarding this, any help would be appreciated.
 

sls314

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Best answers
1
I have a question regarding CKD and Diabetes. I know with Risk Adjustment Coding there is an assumed relationship between CKD and Diabetes and also CKD and Hypertension but if the doctor
only states in the HPI CKD, DM, HTN do I assume the relationship or does the word "with" need to be stated also. Example : HPI states 91 year male with history of CKD, COPD, Anemia, DM, HTN admitted
with SOB. Do I code the DM and HTN ??? I looked back in my CRC book and it states the provider does not need to document the the relationship between these manifestations when they are described
using the word "with" , they may be assumed to be related unless the provider states they are not related. I am going back an forth with my co workers regarding this, any help would be appreciated.

There isn't an assumed link between DM and Hypertension. You would not link those conditions unless the provider specifically stated they were related.

However, there is an assumed link between DM and CKD. There's also an assumed link between CKD and Hypertension. Both of those codes fall under the "with" in the alphabetic index, so per ICD-10 guidelines you can assume they are related unless the provider states otherwise.

In this link to the 2023 guidelines, the "With" convention can be found on page 11:

 
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