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Coding Professionals Clarify the Coding Diabetes Mellitus Interpretation of the Term “With”

Posted on Wednesday, June 15, 2016 12:53 PM

Coding professionals have been experiencing confusion due to the interpretation of the term “with.” Coding Diabetes Mellitus contains several instances of using this guideline in ICD-10-CM, including 53 occurrences of the word “with” under the main term Diabetes.

The ICD-10-CM Official Guidelines for Coding and Reporting states the following at Section I.A.15:
• “With” should be interpreted to “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List
• “With” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order

According to page 11 in the 2016 issue of AHA Coding Clinic, “the subterm “with” in the Index should be interrupted as a link between diabetes and any of those conditions indented under the word “with.” All the subterms listed under “with” can be found in the ICD-10-CM Codebook Index.

An important thing to consider is if the physician documentation identifies that diabetes mellitus is not the cause of another condition, then the condition should not be coded as a diabetic complication, resulting in mandatory review for the entire record. After reviewing the entire record, if there is still uncertainty on whether or not two conditions are correlated, the provider should be questioned. Multiple examples where a query is necessary were published in the February 2013 issue of Journal of AHIMA, which can be reviewed in AHIMA’s online HIM Body of Knowledge.

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