November is National Diabetes Awareness Month and is prompting coders to review coding guidelines for it, suffered by more than 10.9 million U.S. residents.
As all health information management (HIM) coding professionals know that the ICD-10-CM Official Coding and Reporting Guidelines have been approved by the four organizations that make up the Cooperating Parties for ICD-10: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centres for Medicare & Medicaid Services (CMS), and National Centre for Health Statistics (NCHS). Let’s take a look at the coding guidelines for diabetes to ensure that we accurately select and capture the ICD-10-CM code(s) for this disease.
These official coding guidelines are organized into four sections, which includes the structure and conventions of the classification and general guidelines that apply to the entire classification in Section 1. Guidelines for selection of principal diagnoses for non-outpatient settings in Section 2. Guidelines for reporting additional diagnoses in non-outpatient settings. Outpatient coding and reporting in Section 4. To fully understand the guideline, all the rules and instructions need to be coded properly.
Of the 19 conventions that are in Section 1, “with” instruction (No. 15) is often difficult to grasp, as it relates to diabetes.
The word “with” or “in” should be interpreted as “associated with” or “due to” when it appears in a code. The classification presumes a relationship between conditions linked by these terms in the Alphabetic Index or Tabular List.
When looking in the Alphabetic Index, under “diabetes” you would see the “with” listed immediately. Many terms/conditions that are listed “with diabetes.”
We need to make sure to understand and follow official coding and reporting guidelines to have quality coded data.