ICD-10 in Action: Interpreting 'with' or 'in'

December 7, 2017

This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and/or communicate updates to ICD-10 coding conventions.

The ICD-10-CM Manual contains official guidelines for coding and reporting. There are coding conventions, general coding guidelines, and chapter-specific guidelines. These conventions and guidelines are rules and instructions that must be followed to classify and assign the most appropriate code. Understanding these guidelines and conventions is key to reaching the most appropriate code assignment.

  • Conventions. A set of rules for use of the classification independent of the general or chapter-specific guidelines. Coding conventions and instructions of the classification take precedence over guidelines. (e.g., Code First).
  • General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.
  • Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.
As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

Coding convention – Interpreting "with" or "in"

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 (1) the documentation clearly states the conditions are unrelated or (2) 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, rather than in alphabetical order.

Guideline update: In addition to the bolded language, the Official Guidelines for Coding and Reporting for FY 2018 released an update to the "with" coding convention to include "in."

Stay tuned

We will continue to communicate ICD-10-specific information through this article series to review some of the ICD-10 diagnosis code changes. We encourage you to keep up with the latest news and information by visiting the ICD-10 section of our website.

Test Your Knowledge: Coding Scenarios

Code the following medical record notes to obtain the correct code assignment.

Hint: The codes will not always have the word "with" in the narratives. For those, the answer will have an asterisk (*) to indicate the location is either from the Alphabetic Index or Tabular List.

  1. Abortion with retained products of conception. Patient has a metabolic disorder.
  2. Abscess with diverticular disease with the presence of excessive bleeding.
  3. Abscess of kidney with the existence of stones.
  4. Barrett?s esophagus with dysplasia. Refer for immediate endoscopic resection and Barrx ablation.
  5. Bifascicular block with complete right bundle branch block.
  6. Bronchitis with airway obstruction.
  7. Sydenham's chorea resulting from rheumatic fever. There is evidence of heart involvement. Treat with neuroleptics.
  8. Alcoholic cirrhosis of the liver. Patient shows severe build-up of fluid in the stomach.


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