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Coding Clinic is not issuing corrections stating that linkages should not be assumed for diabetes. Rather, it is confirming that this is a new era of associated relationships for diabetes. 

The Coding Clinic published for the second quarter of 2016 indicated that the term “with” means both “associated with” and “due to” when it appears in a code title, alphabetical index, or instructional note in the tabular list. The excerpt goes on to note that a causal relationship is presumed between two conditions linked by these terms. Lastly, the excerpt concludes by noting “the sub term ‘with’ in the index should be interpreted as a link between diabetes and any of those conditions indented under the word ‘with’”.  

Coding Clinic even goes the extra mile and confirms that yes, this now includes diabetes and CKD. The one exception to this new assumed relationship would be if the documentation clearly states that the conditions are unrelated and due to some other underlying cause. While circulatory complications were not specifically addressed, the new advice seems to indicate that all possible diagnoses that can be listed as “with” in the code title should be viewed in this manner. 

I checked, and the wording for vascular manifestations is phrased in exactly the same format as the above mentioned CKD, and the same is true for neuropathy not specified as autonomic.

Clarification for Comparative and Contrasting Diagnoses

The most recently published Coding Clinic also contained this nugget of information for deciding what to do when confronted with a diagnosis that includes multiple comparative and contrasting options: “apply the guideline for uncertain diagnoses.”

The edition goes on to indicate that this would be tantamount to having documentation specifying “possible,” “probably,” “suspected,” “likely,” etc., and we should code the conditions as if they were confirmed. The rationale for doing so is that the diagnostic workup, treatment, and follow-up arrangements would be the same (or similar) for comparative and contrasting diagnoses as they would be for possible, probable, or confirmed conditions.

Poisonings Should be Assumed Accidental if Unknown

Coding Clinic also confirms that ICD-10 follows ICD-9’s example when reporting poisonings that are undetermined. “If the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown,” the guidance reads, “code the intent as accidental.”

They go on to say that the cooperating parties have agreed to create a corresponding general guideline for this situation, which you will probably see in the 2016 Official Guidelines.

DKA without Diabetes Type Must Be Clarified

Coding Clinic directs coding to query for any DKA patient if the specific type of diabetes (type I versus type II) is not specified.  

“Query the physician for clarification regarding the type of diabetes when diabetic ketoacidosis is documented without further specification of type,” the excerpt reads.

This seems like just the type of thing some CDS and coders will moan over and probably ignore, which will inevitably be followed by further aggravation when auditors reject the claim or report cases coded without clarification as “errors.” You were warned.

Confusion and Bad Advice in the Post-ICD-10 Era

Lastly, the new Coding Clinic has an interesting entry that starts: “we were given advice to assign a code for ‘hepatic failure with hepatic coma’ any time ‘hepatic encephalopathy’ is documented.”

My first response was a sarcastic “really?” How is such advice anything but a setup for a claims audit with rejections at best, and an Office of Inspector General (OIG) fraud investigation at worst? It has long been well-established that the diagnosis of hepatic coma requires the patient to be in a coma (or at the very least, in and out of consciousness).   

Regardless of how aggressive you might want to be with calling a depressed state of consciousness a “coma,” it should be pretty obvious that the typical “confusion/altered mental status” that is usually diagnosed as “hepatic encephalopathy” is not going to qualify for the “with coma” ICD-10 code. A lesson to all is to keep your guard up against bad advice. The issue was brought before the Centers for Disease Control and Prevention (CDC) ICD-10 Coordination and Maintenance Committee in March, and we are slated to get new ICD-10 codes for DM with DKA.


Allen Frady, RN, CCDS, CCS

Allen Frady, RN has been in the healthcare industry for over 25 years. He is currently working with 3M as a solutions advisor and specializes in CDI and coding. He is known as an instructor, author, website creator, and podcaster.

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