ICD-10-CM is “fluid”!

That was the statement made by a well-known national expert on ICD-10-CM as she was explaining another ‘clarification’ regarding ICD-10. According to the Thesaurus, ‘Fluid’ can mean unsolidified. It can also mean ‘effortless.’ And then there is ‘adaptable,’ ‘unstable,’ ‘fluctuating’ and ‘unpredictable.’ I think ICD-10-CM is all of those (except effortless) and more. It also makes you want to drink hard liquor in order to cope (not really…I have other coping strategies).

The newest shifting in the guidelines has to do with the word ‘with.’ Yes, that’s right, the short little convention found right after “And” and right before “See” and “See also.”

Here’s the convention:

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetical Index, or an instructional note in the Tabular list.

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

Now, here’s the fluid part…When the word “with” appears with indented sub-entries or essential modifiers underneath, that means that the classification assumes a relationship. No physician documentation is required to connect those two conditions! Example:

Diabetes, diabetic


Arthropathy NEC
Autonomic (poly) neuropathy
Charcot’s joints
Chronic kidney disease

And so on…

That little word has big implications. It means that there is an assumed relationship between diabetes and gangrene, diabetes and ulcers, diabetes and neuropathy, to name a few. All of those times we used two codes because we could not get confirmation that the manifestation was caused by diabetes? We could have been using the combination code instead.

The only time we will not code the condition as caused by diabetes is when there is documentation from the physician that indicates there is another cause for that manifestation. For example, if the physician says the ulcer is a stasis ulcer, then that is NOT a diabetic ulcer. And if unclear, always query the physician.

The Coding Clinic thought they had cleared this up with their 1st quarter publication, however they have been inundated with questions. They will be issuing further clarification in the 2nd quarter publication of The Coding Clinic in June. In the meantime, AHIMA provided the clarification in writing.

So there you have it. Check your alphabetical index before assigning a diabetic code that includes the manifestation. There are some that are not there, e.g. osteomyelitis. That one requires physician confirmation.

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