It’s Time for Coders to Get ‘With’ It

By Lori Amende, RHIA for For the Record

Starting in October 2016, coders began to see a shift in how the key word “with” should be applied in the ICD-10-CM classification system. Since then, additional guidance has been provided to help further clarify this coding convention, including some exceptions to be aware of.

In this edition of Coding Corner, we’ll break down the ICD-10-CM coding guideline related to the key word “with” and exceptions that may apply.

Although not specifically addressed in the ICD-10-PCS guidelines, the key word “with” does come into play when two procedures are performed together during the same operative episode. We’ll review the coding guidelines that pertain to some of these coding scenarios, including an ICD-10-PCS guideline that debuted in October 2020.

ICD-10-CM Coding Guidelines

According to the ICD-10-CM Official Coding Guidelines, the classification presumes a causal relationship between two conditions linked by the word “with” or “in” when these key words appear in the Alphabetic Index or the Tabular List. The two conditions should be coded as related unless the documentation clearly states the conditions are unrelated.

In the example below, notice that the word “with” in the Alphabetic Index is displayed immediately below the main term abscess and is not in alphabetical order. If a patient with diverticular disease is also being treated for an intestinal abscess, the coder would assume a relationship between these two conditions and assign code K57.80, Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding.

Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic) (multiple) (pernicious) (pyogenic)(septic) L02.91
with
diverticular disease (intestine) K57.80

Also addressed in the ICD-10-CM guideline is the word “in.” In the ICD-10-CM classification, the key word “in” can also link two conditions. For example, the Alphabetic Index links the conditions acidosis and type 1 diabetes. When acidosis occurs in a patient with type 1 diabetes, the coder would assume a causal relationship and assign code E10.10, Type 1 diabetes with ketoacidosis without coma.

Acidosis (lactic) (respiratory) E87.2
in type 1 diabetes E10.10

It’s important to remember that two conditions should not be linked if the documentation clearly states they are unrelated. For instance, if a patient presents with esophagitis and gastrointestinal bleeding but the documentation indicates the bleeding is due to another cause, the correct code assignment is K20.90, Esophagitis, unspecified without bleeding.

Esophagitis (acute) (alkaline) (chemical) (chronic) (infectional) (necrotic) (peptic) (postoperative) (without bleeding) K20.90
with bleeding K20.91

If the documentation is unclear whether two conditions are related, it’s appropriate to query the provider for clarification.

Exceptions to the Coding Guideline

There are a couple of exceptions to this coding guideline that coders should keep in mind. The first exception occurs when another guideline exists that specifically requires a documented linkage between two conditions.

Sepsis with organ dysfunction falls into this category. In the ICD-10-CM Alphabetic Index, “with” links sepsis with organ dysfunction. However, per the sepsis coding guidelines, the provider must specifically link acute organ dysfunction with sepsis in order to assign code R65.20, Severe sepsis without septic shock.

Sepsis (generalized) (unspecified organism) A41.9
with
organ dysfunction (acute) (multiple) R65.20

Conditions that are “not elsewhere classified” (NEC) are another exception to the “with” coding convention. This issue was addressed by AHA Coding Clinic in the second quarter 2018 issue on page 6. When NEC entries appear in the Alphabetic Index or Tabular List, the provider must document a link to a specific condition.

Consider a patient with acute cellulitis and a history of diabetes. The coder would not assume a causal relationship between cellulitis and a diabetic skin condition without a documented linkage between the two conditions.

Diabetes, diabetic (mellitus) (sugar) E11.9
skin complication NEC E11.628

ICD-10-PCS Coding Guidelines

While the ICD-10-PCS Coding Guidelines don’t provide specific information on the key word “with,” there are several PCS guidelines that are important when reporting procedures performed during the same session. These guidelines can help coders determine whether both procedures can be coded separately or whether one of the procedures is included in the other.

Multiple Procedures

When multiple procedures are performed during the same session, several factors should be considered, including the objective of the procedure. For example, multiple root operations with distinct objectives performed on the same body part. In this scenario, both procedures can be coded separately. To further illustrate, an open excision of the sigmoid colon performed with creation of a colostomy requires two procedure codes to be assigned.

0DBN0ZZ, Excision of Sigmoid Colon, Open Approach
0D1N074, Bypass Sigmoid Colon to Cutaneous with Autologous Tissue Substitute, Open Approach

Biopsy With Excision or Resection

Next, let’s consider scenarios where a diagnostic procedure is performed with an excision or resection procedure at the same site. In this circumstance both the biopsy and the definitive procedure can be coded. For instance, a percutaneous right breast biopsy with a partial right mastectomy performed via open approach requires both procedures to be reported.

0HBT3ZX, Excision of Right Breast, Percutaneous Approach, Diagnostic
0HBT0ZZ, Excision of Right Breast, Open Approach

Excision for Graft

Coders frequently see procedures performed with excision of a graft during the same operative episode. If the graft is obtained from a separate procedure site, the harvesting of the graft may be separately reported. To further clarify, open coronary bypass of one coronary artery performed with open excision of a right saphenous vein graft is coded as the following:

021009W, Bypass Coronary Artery, One Artery from Aorta with Autologous Venous Tissue, Open Approach
06BP0ZZ, Excision of Right Saphenous Vein, Open Approach

There is an exception to the “Excision for Graft” guideline. A separate code for excision of a graft is not coded when the seventh character qualifier value specifies the site from which the graft was taken. A great example of this is replacement of right breast with autologous deep inferior epigastric artery perforator (DIEP) flap via open approach. In this case, only the replacement code is reported. Coding excision of the DIEP graft would be redundant since the site where the graft was harvested is specified in the qualifier value.

0HRT077, Replacement of Right Breast Using Deep Inferior Epigastric Artery Perforator Flap, Open Approach

Excision/Resection With Replacement
The guidelines for excision/resection with replacement is a new guideline that became effective in October. If an excision or resection procedure is performed with a replacement procedure, both procedures can be coded to identify each distinct objective. For example, when a bilateral mastectomy is performed with transverse rectus abdominis myocutaneous reconstruction, both procedures are reported.

0HTV0ZZ, Resection of Bilateral Breast, Open Approach
0HRV076, Replacement of Bilateral Breast using Transverse Rectus Abdominis Myocutaneous Flap, Open Approach

To further illustrate, if an open excisional debridement of the right ankle tendon is performed with full thickness skin graft taken from the right thigh, both procedures should be coded to fully capture the procedures performed.

0LBS0ZZ, Excision of Right Ankle Tendon, Open Approach
0HRHX73, Replacement Right Upper Leg Skin with Autologous Substitute, Full thickness, External approach

Components of a Procedure

There is one additional guideline that must be considered when coding more than one procedure in the same operative episode. Components of a procedure specified in the root operation as integral to that root operation are not coded separately. This includes procedural steps necessary to reach the operative site and closure of the operative site, including anastomosis of a tubular body part.

The most common example of this specific guideline is open right colectomy with end-to-end anastomosis. Based on the ICD-10-PCS guideline, the anastomosis is considered integral to the colectomy and only the resection code is reported.

0DTF0ZZ, Resection of Right Large Intestine, Open Approach

The word “with” plays a large part in the coding process for both ICD-10-CM and ICD-10-PCS. To ensure complete and accurate coding, it’s imperative that coders pay close attention to both the ICD-10-CM and ICD-10-PCS guidelines as well as the ICD-10-CM Alphabetic Index and Tabular List.