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, 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."
- - chronic disease classified elsewhere NEC D63.8- - chronic kidney disease D63.1.Does the patient have any other chronic diseases besides CKD?I encourage everyone to look at the Index and all the entries at the same level of indentation for Anemia, with/due to, and in. If a patient has more than one of these conditions and anemia and the provider does not specifically document the cause of the anemia, how many anemia codes is the coder supposed to assign?
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) (2019 Official Coding Guidelines)Sincerely,
- - congestive I50.9 - - - with rheumatic fever (conditions in I00) - - - - active I01.8 - - - - inactive or quiescent (with chorea) I09.81What if a patient has HTN and multiple valve disease with CHF? Multiple valve disease is assumed to be rheumatic.How many CHF codes should be assigned. Should I09.81 be assigned? If the underlying cause is not documented the term "with" means the connection is assumed.These are just 2 examples. I am pretty sure if one reviews the entire Index, other examples can be found. This is a problem with the new "with"/"due to"/"in" Guideline. Also note how terms after "with", "in" and "due to" are inconsistent. This is especially true for anemia. Per the Guideline, all entries should be evaluated after these three terms. The Guidelines state the three terms are interchangeable. I try to use a little "common sense" when I code. Quite often "the connection" is specified - "anemia due to ckd". However, take it to an extreme. As another poster suggested, what if a patient with CKD, a GI Bleed, active neoplasm receiving chemotherapy and a deficiency is diagnosed with "anemia". How many codes are you going to assign? Are you going to send cases like this back for a query? How many codes are you going to enter to see if there is any DRG change?
- due to (in) (with)
- - antineoplastic chemotherapy D64.81
- - blood loss (chronic) D50.0
- - - acute D62
- - chemotherapy, antineoplastic D64.81
- - chronic disease classified elsewhere NEC D63.8
- - chronic kidney disease D63.1
- - deficiency
- - - amino-acid D53.0
- - - copper D53.8
- - - folate (folic acid) D52.9
- - - - dietary D52.0
- - - - drug-induced D52.1
- - - molybdenum D53.8
- - - protein D53.0
- - - zinc D53.8
- - dietary vitamin B12 deficiency D51.3
- - disorder of
- - - glutathione metabolism D55.1
- - - nucleotide metabolism D55.3
- - drug -see Anemia, by type -see also Table of Drugs and Chemicals
- - end stage renal disease D63.1
- - enzyme disorder D55.9
- - fetal blood loss P61.3
- - fish tapeworm (D.latum) infestation B70.0 [D63.8]
- - hemorrhage (chronic) D50.0
- - impaired absorption D50.9
- - loss of blood (chronic) D50.0
- - myxedema E03.9 [D63.8]
- - Necator americanus B76.1 [D63.8]
- - prematurity P61.2
- - selective vitamin B12 malabsorption with proteinuria D51.1
- - transcobalamin II deficiency D51.2Look at all the terms at the same level of indentation. In certain situations how many anemia codes are you going to assign? What if the patient has CKD, cancer, is on chemotherapy, documented blood loss, some sort of dietary deficiency, and multiple chronic conditions and the physician documents only "anemia" or "anemia of chronic disease"? Are you going to assign one anemia code or six or some other number of codes in between? What makes CKD any more special than all the other conditions listed in the index? I have brought up this point before.
The physician does not have to link anemia with the CKD in order for you to code it that way. CKD is listed under anemia DUE TO, (IN) (WITH). Anything listed that can be assumed. Your code would be D63.1
Brenda Mohs, RHIT
Home Health & LTC Medical Coder
What is confusing is that it states, "in the code title," but per the index, anemia of CKD is under:Anemia due to (in) (with) chronic kidney diseaseAre we to assume that due to = with as well?The only condition under anemia that have the 'with' are the anaerobic glycolysis and pentose phosphate pathway.Based on this assumption, if someone has anemia and CKD, you always assume the relationship.Looking at the index, some sections have with (due to) (in) and due to (with) (in) while other entries have with and due to not with the non-essential modifiers. Aren't the non-essential modifiers not supposed to change your code?I think they provider should link the anemia and CKD to code out D63.1.Thoughts?