Wiki "With"

[Summeravenue]

We've been discussing the word "with" in the coding guidelines. We know that the provider does not have to explicitly link diabetes and neuropathy. My question is, 1. does the provider have to document diabetes with neuropathy or 2. in the A/P provider just states:
1. Diabetes
2. Neuropathy
For # 2, the fact that the patient has these two conditions, do we link them?

 

[chembree]

Yes....

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.