Wiki Coding Diabetes with underlying cause

[reac2005]

We are having a debate in my office on what needs to be documented when a patient has Diabetes and other conditions (ie: retinopathy or neuropathy) and doctor does not specify that the underlying condition is related to the Diabetes.
Some say you can assume the relation and code Diabetes with retinopathy. Others say you cannot assume if documentation does not use linking words (ie with, related to ) codes would need to either query doctor or code separately.
Can someone give some clarification?
Thank You
Christine

 

[mitchellde]

Read your coding guidelines. ICD-10 CM did change this and due to the code book linking conditions in the alpha index with the word “with”. These are now assumed to be causal conditions. Go to the index and look under diabetes, then you see the word with indented under the word with are all the conditions that are considered automatically casual unless otherwise documented as not. The coding guidelines and coding clinics are clear in their instructions that the documentation does not need to link these conditions.
From the coding guidelines:
With”
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

 

[reac2005]

Thank you. I will take this back to my team.