Coding Diabetes Mellitus with Associated Conditions

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There has been some confusion among coding professionals regarding interpretation of the coding guideline of “with.”  An area that contains many instances of using this guideline in ICD-10-CM is coding Diabetes Mellitus with associated conditions. There are 53 instances of “with” subterm conditions listed under the main term Diabetes.

The ICD-10-CM Official Guidelines for Coding and Reporting states the following at Section I.A.15:

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 word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

There was a recent clarification regarding this guideline published in the first quarter 2016 issue of AHA Coding Clinic on page 11. According to this clarification, the subterm “with” in the Index should be interrupted as a link between diabetes and any of those conditions indented under the word “with.”

Following this guidance as we look to the main term Diabetes in the ICD-10-CM Codebook Index, any of the conditions under the subterm “with” such as gangrene, neuropathy, or amyotrophy (see below for the full list) can be coded without the physician stating that these conditions are linked. The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system.

The following are all the subterms under “with” under the main term Diabetes in the ICD-10-CM Codebook Index:

Subterms Under "With" Under Diabetes Mellitus

To clarify the guidance, for example to accurately assign the code E11.319, type 2 diabetes mellitus with retinopathy, the physician documentation does not need to provide a link between the diagnoses of diabetes and retinopathy; this link can be assumed since the retinopathy is listed under the subterm “with.” Another example to accurately assign the code E11.40, type 2 diabetes mellitus with neuropathy, the physician documentation does not need to provide a link between the diagnoses of diabetes and retinopathy; this link can be assumed since the neuropathy is listed under the subterm “with.” This sounds easy enough but it can be confusing figuring out how to interpret this guideline, especially because this was not the case in ICD-9-CM for coding the associated conditions under Diabetes.

An important thing to remember is that if the physician documentation specifies that diabetes mellitus is not the underlying cause of the other condition, then the condition should not be coded as a diabetic complication. With this in mind, the entire record needs to be reviewed. After reviewing the entire record, if it is not clear whether or not two conditions are related, the provider should be queried. Multiple examples of cases in which a query is necessary were published with an article in the February 2013 issue of Journal of AHIMA can be reviewed in AHIMA’s online HIM Body of Knowledge at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018.

The generation of a query should be considered when the health record documentation:

  • Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
  • Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • Provides a diagnosis without underlying clinical validation or is unclear for present on admission indicator assignment

For more examples read the article “Interpreting ‘With’ in ICD-10-CM,” published in the May issue of AHIMA’s CodeWrite e-newsletter. Click here to view.

You can also discuss this topic on the AHIMA Engage website at http://engage.ahima.org/communities/himcontentcommunities, or discuss in the comments below.

Gina Sanvik, MS, RHIA, AHIMA-approved ICD-10-CM/PCS Trainer, is director, coding and data standards, HIM practice excellence at AHIMA. In her role she provides technical expertise for the creation and review of AHIMA’s coding-related products such as webinars, Practice Briefs, educational courses, and articles. She also works with the AHIMA coding service product AHIMA CheckPoint™: Code-Check.

30 Comments

  1. Gina, Thank you for this very informative article. I hadn’t yet noticed this in the guidelines. If I could make a request, would you mind addressing the question of postoperative atrial fibrillation in an article?

    Some coders are reading the ICD-9 coding clinic which instructed that a complication code should be assigned even when “postoperative atrial fibrillation” was not specified as a complication. That was written at a time when “post-operative” was a sub-term in the index under atrial fibrillation. The index has since been revised though, and “postoperative” is no longer a sub-term, but has been moved to main index entry. This has caused uncertainty as to whether the instructions to code the complication still apply. An ICD-10 monitor article was written recently which expressly stated that the complication should not be reported in ICD-10, however our coders have expressed concern because the article was written by a CDI author who did not have a coding credential listed. Other coders feel that the index still instructs that diagnoses stated as “postoperative x” (as opposed to merely happening in the postoperative time fram) are coded to the complication by body system, per index instructions, but they are contradicted by other coders expressing concerns about the guidance that specifes that conditions must be specified as complications… yet that guidance existed even at the time of the original coding clinics that instructed us to code the complication.

    Can you do an article on the coding of conditions such as “postoperative atrial fibrillation” or “postoperative ileus” given the revisions to the index that have occurred since the original ICD-9 guidance?

    Post a Reply
    • Thanks for a very articulate, informative post, Gina!

      Great thoughts, Jonathan. These are questions our group is struggling with as well. Thanks for asking.

      We are also debating, in home health specifically, how we may code certain drains such as biliary drainage tubes (short term non-vascular catheters were not to be coded at all in home health in ICD-9; now we have no guidance at all) vs. PleurX drains which are long-term drains placed by interventional radiology. These both qualify under home health guidelines as surgical wounds but don’t qualify for coding of any aftercare codes. Most coders disagree that the complexity of care is fully explained by simply coding either of these scenarios under Z48.01, but we had instructions under ICD-9 not to use any code other than the current equivalent of Z46.82.

      Are you able to clarify these additional scenarios for us?

      Thanks much, Gina.

      Post a Reply
    • In our ICD10 coding book on page 500, chapter 4, example 2, Type of diabetes not documented:

      Patient presents with both diabetes and hypertension. Code F119 and i10. Since the documentation and no complication where noted, the default code it E119.

      In this example it is NOT assumed because there is no documentation that states “DUE TO” or “WITH”.

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      • Correction meant to type E119 for dm instead of F119. Still learning my alphabet.

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    • Thank you for the comment, Jonathan! I’m glad that this blog was helpful for you.

      I think the postoperative conditions coding topic would be good for future blogs so thanks for the suggestion. In the meantime, here is a link the AHIMA Engage Community site for Coding, Classification and Reimbursement. This may provide a greater opportunity for an answer and there is always discussion on many coding hot topics. http://engage.ahima.org/communities/himcontentcommunities

      Post a Reply
  2. I work for Mercy IDEC which stands for Iowa Diabetic and Endocrinology clinic. Is there a certification exam for just this specity?

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    • Hi Alicia, We do not have a specific specialty certification exam for this area only. I’m including the link for the certifications that we offer.

      http://www.ahima.org/certification

      Thanks, Gina

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  3. Hi Gina,

    I apprciate your article as the interpretation of the referenced AHA Coding Clinic is in debate among many coders.
    My concern is the statement that “the physician documentation does not need to provide a link…”. The definition of “with” hasn’t changed from ICD-9 to ICD-10 and there was the additional ICD guideline guidance because there was the issue of wether or not the term “with” could be used as a “linking term” in the clinician documentation like other terms such as “due to” or “diabteic” – not that the documentation didn’t need to show the linkage.
    My example for this is that the term “with” is also in the index when looking up both “Hypertenstion with heart failure” as well as “Hypertension with CKD” – but it is well documented that there is NOT an assumed linkage for the Heart Disease and hypertension but there is “exception” of assumed linkage for the Hypertension and CKD.
    My concern is that this interpretation of the term “with” and the AHA Coding Clinic article is that it is leading the coders to make clinical assumptions. Instead of finding the link in the documentation and using the indexing term “with” to find the appropriate combination code. Your thoughts?

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    • I Thank you also. I’m a CDI RN and learn something new every day. First my hat is titled to all the coders, it’s a hard test to keep all the rules and regulations in mind. I also consider regarding the linkage with “with” and heart disease. I was taught the likinage of Heart dis. N CKD along with htn and diabetes all went together but when a Dr Dx type 2 with neuropathy or etc this would be a separate code due to their is no code when you link with CKD. If there’s anything I’m missing please let me know. As a concurrent coder we we’re taught words: with, due to, likely or probably should be coded as actually problems. Thank you all. I learn a lot from yall.

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    • Hi Sheila and thanks for your comment.
      I agree that this area has been confusing and definitely a hot coding topic due to guiding the coding professionals to interpret “with”. The ICD-10-CM Official Guidelines for Coding and Reporting also states the following at I.A.15:

      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 word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

      The 1st Quarter Coding Clinic is giving examples of this and how it would fit with diabetes but as you state there are times this will need to be questioned. Reading the entire record to make sure the physician does not document that the conditions are due to some other underlying cause is important. As always, the coding professional should consider sending a query to the physician if needed.

      There was more clarification on this subject just published in the 2nd Quarter Coding Clinic pages 36-37.
      Thanks,
      Gina

      Post a Reply
  4. Question came up today–patient had DM and atherosclerosis of lower extremity. It was suggested to code this as E11.51-DM with peripheral angiopathy. Dorland’s identifies angiopathy as “any disease of the blood vessels or lymphatics”. I am not so sure I agree with this? I think DM should be coded separate from atherosclerosis of lower extremity (no link).

    If we link in situations like this, does that mean everytime we see DM and OA, we code E11.618–DM with arthropathy NEC, since Dorland’s identifies arthropathy as “any joint disease”.

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    • Hi Bonya,
      Great question!!

      It is my understanding for conditions not specifically linked by these relational terms in the classification under the subterm “with” that provider documentation must link the conditions in order to code them as related.

      Here is a link the AHIMA Engage Community site for Coding, Classification and Reimbursement. This may provide a greater opportunity for an answer and further discussion on this topic. http://engage.ahima.org/communities/himcontentcommunities
      Thanks,
      Gina

      Post a Reply
  5. The ICD9 Guidelines also state:

    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 word “with” in the alphabetic index is sequenced immediately following the main term, not in alphabetical order.

    I have a couple of questions regarding this article. We’ve had the same guideline in ICD9, but this article looks as if it’s directing us to automatically associate any of these conditions with diabetes even if not stated by the physician. Why is this only being applied to diabetes if we are to interpret “with” this way? Also, why are we applying the word “with” in a different manner even though we’ve had this guideline in ICD9?

    Post a Reply
    • My understanding is that it applies to the entire Codebook, not just under the term diabetes when “with” is used as a subterm. The AHA Coding Clinic 1Q 2016, page 11 had recently published clarification on this guideline with some examples for coding diabetes but it’s not limited to diabetes only. It seems like there has always been some confusion on how to interpret “with” under Diabetes. There was also just a clarification published in the 2nd Quarter Coding Clinic pages 36-37 which may be helpful.

      The ICD-10-CM Official Guidelines for Coding and Reporting states the following at I.A.15:

      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 word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

      Thanks for your comments,
      Gina

      Post a Reply
      • OK, Please forgive me. I feel like I am beating a dead horse but I am trying to wrap my head around this concept.

        I, too, am struggling to use all of these combination codes when the physician isn’t documenting a connection whether directly or implied.

        I interpreted the 15th guideline in the ICD 10 Convention that states, “The word ‘with’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in the code title, alphabetic index or instructional note” to be directing us, as coders, to use those codes when the PHYSICIAN has made the association whether direct or implied.

        Again, I apologize. I just want to make sure this is clear. This is a huge change.

        Post a Reply
        • Monica,we have the same concerns as you do and have sent in a question to the AHA Coding Clinic for clarification. We do not have access yet to the 2nd Quarter 2016 Coding Clinic, as referenced by Gina,so we wrote to them in the hopes of getting clarification sooner. My team gives coding guidance to a large number of coders and this has really thrown everyone for a loop.

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  6. As big of a change from ICD9CM to ICD10CM that the diabetes complications is appearing to have, I am wondering why there has been no transparency in these coding guidelines regarding diabetic complications. It seems as though this change should have been called out in the ICD10CM training in comparing what is new or different from ICD9CM, and at a minimum should have been included in the Diabetes chapter. Additionally, this conversation only arose when a specific question was submitted to AHA Coding Clinic and is now leaving all seasoned coders baffled and quite anxious to hint at with providers or even put into practice. I would also question why this nuance was not included in AHIMA’s ICD10CM/PCS documentation tips document. I do agree this presents a huge gap that will require AHA to further respond to.

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    • Linda, I agree with you. I was told that the ICD-10 would be “more” specific. As it turns out, it is far less specific than the former manual in my eyes. It causes more questions and confusion because of less specificity. Is it really the E and V codes that are what were supposed to be “more” specific? It seems that way. Do you agree?

      Post a Reply
    • Hi Linda,
      Thanks for your comments. Since the situation didn’t arise until the 1st Quarter 2016 Coding Clinic, thus that is why it wasn’t addressed in the ICD-10 Academies. You might have seen this already but if not, the AHA Coding Clinic has come out with a clarification in the 2nd Quarter 2016 Coding Clinic pages 36-37.
      Thanks,
      Gina

      Post a Reply
  7. Along with with and due to I often see the term “In setting of” which in my eyes does not make the link between codes such as in cases of UTI in a patient with a chronic siprapubic tube, Is there any know guideline for the term “In setting of”

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  8. Hi Linda

    Thanks for a very good articulate

    We are having a dount regarding that Patient is having gangrene and foot ulcer. And patient is having history of diabetes and HTN. But the provider doesnt mention that any cause and effect relationship. And there is no long term of medications documented in the chart. Still we have to consider relations or we have to code separately. Please clarify the doubt with codes.

    Post a Reply
  9. Hello all and thank you so much for this conversation.

    I have to point out one thing. The guidelines state that “with” should be interpreted to mean…in the index and tabular; the guidelines don’t say “providers documentation”. The providers documentation of a causal relationship still means exactly that, the documentation must say that a complication/manifestation is a result of diabetes using the terms due to, etc. The “Code description” in both the tabular and index use the term “with” to say the same thing. It does not mean that the provider still should not indicate in the documentation that one thing is caused by another.

    Just sayin. This is the way that I interpret it.

    Thank you all again!

    Michele L. Davis, CPC, CPC-I, CRC
    AHIMA Approved ICD-10-CM Trainer
    AAPC-Tucson Cactus Coders, Education Officer

    Post a Reply
    • See Diabetes Mellitus with Associated Conditions
      Coding Clinic, First Quarter 2016: Page 11
      Coding advice or code assignments contained in this issue effective with discharges March 18, 2016.

      Question:
      The ICD-10-CM Alphabetic Index entry for ‘Diabetes with’ includes listings for conditions associated with diabetes, which was not the case in ICD-9-CM. Does the provider need to document a relationship between the two conditions or should the coder assume a causal relationship?
      Answer:
      According to the ICD-10-CM Official Guidelines for Coding and Reporting, the term “with” means “associated with” or “due to,” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List, and this is how it’s meant to be interpreted when assigning codes for diabetes with associated manifestations and/or conditions. The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system. Assumed cause-and-effect relationships in the classification are not necessarily the same in ICD-9-CM and ICD-10-CM.
      However, if the physician documentation specifies diabetes mellitus is not the underlying cause of the other condition, the condition should not be coded as a diabetic complication. When the coder is unable to determine whether a condition is related to diabetes mellitus, or the ICD-10-CM classification does not provide coding instruction, it is appropriate to query the physician for clarification so that the appropriate codes may be reported. (See ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.15.)
      In addition, the following advice published in Coding Clinic, Third Quarter 2012, page 3, also applies to ICD-10-CM:
      “It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., hypertension with chronic kidney involvement). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. However, the entire record should be reviewed to determine whether a relationship between the two conditions exists. The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, query the provider.”
      Diabetic Foot Ulcer
      Coding Clinic, First Quarter 2016: Page 12
      Coding advice or code assignments contained in this issue effective with discharges March 18, 2016.
      Question:
      A patient, who is a type 2 diabetic, is admitted with a chronically infected ulcer of the left mid-foot. The provider documented, “Diabetic foot ulcer with skin breakdown, positive for Methicillin resistant Staphylococcus aureus (MRSA) infection.” She also had been diagnosed with polyneuropathy, end-stage renal disease (ESRD), on hemodialysis maintenance. Does the ICD-10-CM assume a cause-and-effect relationship between the diabetes mellitus, the foot ulcer, polyneuropathy and ESRD? How should this case be coded?
      Answer:
      ICD-10-CM assumes a causal relationship between the diabetes mellitus and the foot ulcer, the polyneuropathy, as well as the chronic kidney disease. Assign code E11.621, Type 2 diabetes mellitus with foot ulcer, as the principal diagnosis. Codes L97.421, Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin; E11.42, Type 2 diabetes mellitus with diabetic polyneuropathy; B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of disease classified elsewhere; E11.22, Type 2 diabetes mellitus with diabetic chronic kidney disease; N18.6, End stage renal disease; and Z99.2, Dependence on renal dialysis, should be assigned as additional diagnoses.
      Diabetes Mellitus and Osteomyelitis
      Coding Clinic, First Quarter 2016: Page 13
      Coding advice or code assignments contained in this issue effective with discharges March 18, 2016.
      Question:
      A woman, who has had type 1 diabetes for over 40 years, developed chronic osteomyelitis of the right heel and presents to the infectious disease clinic for follow-up. The provider also noted, “Chronic renal impairment (creatinine 290) due to diabetes.” While at the clinic the patient became hypoglycemic and was treated. Does ICD-10-CM assume a relationship between diabetes and osteomyelitis when both conditions are present? How should this case be coded?
      Answer:
      No, ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such. This information is consistent with that previously published in Coding Clinic, Fourth Quarter 2013, page 114.
      Assign code M86.671, Other chronic osteomyelitis, right ankle and foot, as the first-listed diagnosis. Assign codes E10.649, Type 1 diabetes mellitus with hypoglycemia without coma, E10.29, Type 1 diabetes mellitus with other diabetic kidney complications, and N28.9, Disorder of kidney and ureter, unspecified, as additional diagnoses.

      Post a Reply
  10. I have a case wherein patient was admitted due to uncontrolled HTN. Patient has history of ESRD and DM also. What will be the appropriate principal diagnosis for this case? Is it the E11.22 or the I20?

    Post a Reply
    • Hi Karen, I would recommend that this question be posted on the AHIMA Engage Community (e.g. Coding, Classification and Reimbursement Community; Confidentiality, Privacy and Security; etc). This may provide a greater opportunity for an answer. http://engage.ahima.org/communities/himcontentcommunities

      Thanks!!
      Gina

      Post a Reply
  11. Hello,
    I will be sitting for my CRC next month, and I was wondering if I come across this issue of DM with complication on my exam, do I follow these new rules?

    Post a Reply
  12. Hi Gina,

    I have a case, Patient have DM and glaucoma, Can I code E11.39 and H40.9

    Thanks.

    Post a Reply
  13. Patient final diagnosis is ESRD with Diabetes with hypertension with CHF. What are my codes.

    Post a Reply

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