Cracking the Code

Understanding “Due to” or “Associated With” When Coding

The Second Quarter 2023 Coding Clinic discusses the use of terms such as “due to” and “associated with” and the relationship of the “with” classification.


When we navigate through the ICD-10-CM guidelines, I.A.15. states, “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 (either under a main term or subterm), 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. The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.”

Q: A patient visits the primary care physician for follow-up of hypertension, hypothyroidism, chronic kidney disease, and anemia. Since hypothyroidism is an endocrine disorder, some coding professionals believe hypertension and hypothyroidism are linked by the following index entry: Hypertension, hypertensive due to endocrine disorders I15.2. Even though provider documentation did not link the conditions, some coding professionals believe the term “due to” has the same connotation as “With” based on the Official Guidelines for Coding and Reporting, Section 1.A.15. Should code I15.2, Hypertension secondary to endocrine disorders, be assigned, in the absence of provider documentation linking the two conditions?”
A: Per Coding Clinic for ICD-10-CM/PCS, Second Quarter 2023, Page 16, “No. The classification does not assume a causal relationship between hypertension and hypothyroidism. In the guideline, the use of terms due to and associated with is intended to explain the inference of “With” in the classification. However, these terms are not interchangeable, and the connotation in the Alphabetic Index and Tabular List is different. The classification only presumes a causal relationship between certain conditions linked by the terms “With” and “In.” Conversely, when conditions are linked by the term due to, provider documentation must explicitly indicate a causal relationship. Furthermore, the term “endocrine disorders” is very broad; it can be applied to many conditions in the endocrine system; and the “With” guidance does not apply to index entries that cover broad categories of conditions. For those conditions, the provider must clearly document a causal relationship.”
Reference: FY 2023 ICD-10-CM Guidelines, Coding Clinic for ICD-10-CM/PCS, Second Quarter 2023, Page 16
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