ICD-10-CM Guideline I.A.15 “With”

Are you still struggling to apply the ICD-10-CM guideline I.A.15 “With”?  If so, you won’t be the only one.  You will recall this guideline was clarified in recent years to indicate that the word “with” presumes a causal relationship to exist between the terms linked by that word in the index unless the physician indicates there is no relationship or another guideline exists that states the conditions must be linked with specific documentation.  In this edition of “In the kNOW”, we will look at how this guideline should be applied to G.I. bleeds by exploring the following scenarios.

A patient presents to the ER with G.I. bleeding and is taken to the endoscopy suite for an EGD.  The final diagnosis documented from the procedure is that of an esophageal ulcer.  How should this be coded?

If your first thought is K22.10 (ulcer, esophagus) and K92.2 (bleeding, gastrointestinal), let’s review.  Applying the guideline I.A.15 “With”, we can use a combination code found under ulcer, esophagus, with bleed, K22.11.  Because the index entry under Ulcer, esophagus, is “with bleeding”, the classification is permitting the assumption of a causal relationship between these two conditions.  It is not necessary for the physician to indicate a relationship in his/her documentation.    

Now, let’s apply the guideline to this example.  Patient with hematochezia undergoes a colonoscopy with final documentation indicating diffuse diverticular disease of the large intestine.  Again, using the index, we identify diverticulosis, large intestine, with bleeding leading to combination code K57.31. 

Similar index entries can be found for gastric ulcers, angiodysplasia, gastritis, and diverticulitis with bleeding.  Again, the classification is making a coder’s job easier by permitting the assumption of the causal relationship.  It is not necessary to query the physician, as we have classification guidance on the assignment of the combination code. 

3rd Qtr. 2017 Coding Clinic (page 27) provides clarification on this topic as well.  It does warn coders to watch for any documentation that would indicate the conditions are not related though.  In those circumstances, if we revisit our first example and the physician indicated the bleeding was not from the ulcer, we would definitely assign K22.10 and K92.2.

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.