Q&A: “With” as linking language

Q: The word "with” is interpreted to mean "associated with " or “due to" per the Official Guidelines for Coding and Reporting. Although "with" can link two diagnoses, it does not represent a cause-and-effect relationship. But we also need to use direct linking with wording such as "UTI due to foley catheter." I’m confused because I never use “with” to show cause and effect, I use “due to” or “associated with.” Why do the Official Guidelines say this?

A: This is a great question and one that many get confused by. I will start with a little history lesson. Back in the days of ICD-9, we had to query providers for linking language on just about everything. You should have seen the look on the vascular surgeon’s face when I asked if the patient’s peripheral vascular disease (PVD) was due to diabetes.

When we changed to ICD-10-CM, the Coding Conventions, Alphabetical Index, Tabular list, and Official Guidelines for Coding and Reporting changed when it came to causal connection language and assumed causal connections.

The Coding Conventions instruct (bold added):

The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), 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 or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).

For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, 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 or subterm, not in alphabetical order.”

What the convention is saying is that if the word “with” is in the code title, such as diverticulitis with abscess, the causal connection has been made. We would not need to query for a causal connection. If the word “with” is under the main term or subterm in the Alphabetic Index, the causal connection has been made.

The best example of this is diabetes. Looking at the term Diabetes, Type II in the Alphabetic index, you will see directly underneath it the word “with” and then a list of diagnoses commonly associated with Type II Diabetes. The causal connection has been made, so we would not have to ask a vascular surgeon if the PVD is due to the patient’s diabetes because the connection has already been made in the Alphabetic Index.

However, for conditions that do not have the word “with” either in a code title, listed in the Alphabetic Index, or specified in the Tabular List, a causal connection needs to be made. In this case, the “with” rule does not apply, meaning we cannot use the word “with” as linking language. The classic example of this is a patient that has a chronic foley who is admitted and the documentation states “UTI with chronic Foley.” The cause-and-effect relationship is not established in this statement. In order to appropriately capture a cause-and-effect relationship, the documentation should state “UTI due to chronic Foley.” The cause-and-effect relationship has been established. This is important because the guidelines do instruct that a complication of medical or surgical care will sequence as the principal diagnosis if present on admission.

The DRG will likely change as a result of appropriately capturing the cause-and-effect relationship with the correct linking language. Understanding the difference is important so you know when to query a provider and when not to. I hope this helps alleviate some of the confusion.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.