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. 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. 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. If the word “with” is under the main term or subterm in the Alphabetic Index, the causal connection has been made. We would not need to query for a causal connection. 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. The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.” 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”).įor 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 classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. 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 Coding Conventions instruct (bold added): 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. 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. Back in the days of ICD-9, we had to query providers for linking language on just about everything. I will start with a little history lesson. 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?Ī: This is a great question and one that many get confused by. Although "with" can link two diagnoses, it does not represent a cause-and-effect relationship. Try 1 Try 2 Gain n x ˉ s x x ˉ s x x ˉ s x Coached 427 500 92 529 97 29 59 Uncoached 2733 506 101 527 101 21 52 \begin & 2733 & 506 & 101 & 527 & 101 & 21 & 52 \\Ĭoached Uncoached n 427 2733 Try 1 x ˉ 500 506 s x 92 101 Try 2 x ˉ 529 527 s x 97 101 Gain x ˉ 29 21 s x 59 52 ĭo the scores of students who are coached increase significantly? Carry out the proper test.Q: The word "with” is interpreted to mean "associated with " or “due to" per the Official Guidelines for Coding and Reporting. Starting with their Verbal scores on the first and second tries, here are the summary statistics. A random sample of students who took the SAT twice found 427 who were coached and 2733 who were uncoached. Of course, the scores of students who retake the SAT without paying for coaching generally improve. Coaching companies claim that their courses can raise the SAT scores of high school students.
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