If the physician documents that the condition is causal then you code the causal(underlying) condition first. For instance, a diabetic ulcer, is coded as the 250.8x fisrt then the ulcer 707.1x second, hypertensive heart disease is 402.9x, but diabetes with an ulcerative condition is 707.1x and 250.0x, and heart disease with HTN is the heart disease code with 401.9. So it all depends on how the physician documents the condition.
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