On the surface, this new rule seems great--here's an excerpt from AHA's Coding Clinic:
"The ICD-10-CM Alphabetic Index entry for 'Diabetes with' includes listings for conditions associated with diabetes...Does the provider need to document a relationship between the two conditions or should the coder assume a causal relationship?"
"... the term "with" means "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 assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves, and circulatory system....
It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association ...When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. .... The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related...."
All of this sounds like it should make things easier for both physicians and coders. However, the opposite can be true.
As coders, it's our job to educate physicians on coding rules. But I think this Coding Clinic ruling, and other similar ones, as potential minefields. Physicians, by the very nature of their jobs, have to keep current with a large amount of very complex information. Educating physicians on a rule like this has the potential to backfire.
The physician is unlikely to go to the ICD-10 and check the code title, then to the Alphabetic Index, and continue on to search for instructional notes in the Tabular list to determine if the term "with" is present. That may lead them to assume that the rule applies in cases where it doesn't.
There is no harm in documenting the association between two diseases, but there can be tremendous harm (in an audit situation) in failing to document that association if the rule does not apply.
So, how can we best educate our physicians? I think that explaining that there are some limited cases where a causal relationship is assumed is a good approach. But with that explanation, physicians must also be told that the majority of the time, a causal relationship is NOT assumed, and that trying to remember which is which is difficult for coders who do this all day long. The safest approach is to state the causal relationship, which ensures that coders can code what the physician actually means. Give them examples--and make sure those examples demonstrate how this can be done without significantly increasing their workload. By simply adding a few words, the physician can convey their clinical judgement that one disease cause another--for example "CKD 4 2o DM2" clearly shows the physician's diagnosis that type 2 diabetes mellitus caused the patient's stage 4 kidney disease. And it means that doctors don't have one more thing to remember.
While telling our physicians about these rules in detail may seem like a good idea, it can increase the likelihood of errors.
What coding and educational challenges do you face? Do you have ideas for helping providers navigate documentation issues? Be sure to leave us a comment, or send ideas you would like to share to firstname.lastname@example.org.