Coding Guidelines and the Gift of “With”

Coding Guidelines and the Gift of “With”

by Angela Gerbert, BS, CDIP, CCS, CIC, CPC-I

This year, the Official Guidelines for Coding and Reporting have made great strides in clarifying the concept of “with.” This clarification on how to apply the word “with” in the alphabetic index is a gift.

The gift of “with.”

For fiscal year 2017 (bold text is new for this year):

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

 

In other words, if the subterm in the index says “with,” the documentation does not have to link the two conditions.

The guidelines also remind us that coding the condition hypertensive heart disease is included in the concept of “with.”

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. 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 hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the classification, provider documentation must link the conditions in order to code them as related.

 

Therefore, unless the provider specifically documents a different cause of heart disease (other than hypertension), the gift of “with” applies.

How is this a gift? When two conditions are present and the word “with” is under the main term the process of deciding which code to select is simplified.

What next? Educate your providers to make them aware of the guideline. Be sure they understand what the classification system will assume if they do not identify a specific cause. Then leave it in your provider’s capable hands for documentation.

About the Author

Angela Gerbert
Angela Gerbert applies a hands-on approach to her role as the Director of Education for Libman Education. Whether overseeing the work of subject matter experts including nationally recognized coding authorities; challenging instructional designers to deliver content in a way that is both engaging and memorable; or tapping her 25 years’ experience in inpatient, outpatient, and emergency room coding to write coder-friendly courses herself, Angela is responsible for ensuring that our training is accurate, easily accessible, and challenging.

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