ICD-10 coding challenge: Updated coding guideline A.15 “With”

Oct. 31, 2016 / By Sue Belley, RHIA

A 47-year-old patient was admitted to the hospital with a chief complaint of an ulcer at the base of his left great toe. Patient has a history of diabetes mellitus, type 2, nephropathy with CKD stage 3, GERD, asthma and esophagitis. The patient’s medications include insulin, a proton pump inhibitor and a steroid inhaler. After examination, it was determined that this was a diabetic foot ulcer with exposure of the fat layer. The wound was cultured and the patient was placed on IV antibiotics. Two days later the patient was taken to the Operating Room for an excisional debridement of the ulcer down to the bone. The patient was discharged from the hospital on day #5 with a diagnosis of poorly controlled diabetes mellitus with diabetic foot ulcer and acute osteomyelitis. The patient is sent home with IV antibiotic therapy and instructions to follow up in outpatient Wound Clinic for outpatient treatment of the ulcer. Please assign diagnosis and procedure codes for this scenario.


E11.621  Type 2 diabetes mellitus with foot ulcer
L97.522  Non-pressure chronic ulcer of other part of left foot with fat layer exposed
E11.65    Type 2 diabetes mellitus with hyperglycemia
Z79.4       Long term (current) use of insulin
E11.69     Type 2 diabetes mellitus with other specified complication
M86.172 Other acute osteomyelitis, left ankle and foot
Z79.2        Long term use of antibiotics
E11.21     Type 2 diabetes mellitus with diabetic nephropathy
E11.22     Type 2 diabetes mellitus with diabetic chronic kidney disease
N18.3       Chronic kidney disease, stage 3
K21.0        Gastro-esophageal reflux disease with esophagitis
J45.909     Unspecified asthma, uncomplicated
Z79.51       Long term use of inhaled steroids
0KBW0ZZ  Excision of left foot muscle open approach


This month’s scenario provides us with an opportunity to examine the updated Guideline A.15 “With” in the FY 2017 ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2016. The updated guideline states that “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. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.”

In this scenario, the nephropathy, chronic kidney disease and osteomyelitis are not explicitly linked to diabetes mellitus by the provider. However, these three conditions are indexable under the main term, Diabetes, subterm, With, which is a perfect example of the classification presuming a causal relationship.

The same goes for GERD and esophagitis. These diagnoses are not linked in the provider documentation but the index presumes a causal relationship (see Disease, Gastroesophageal, With esophagitis).

Sue Belley, RHIA is a clinical content development manager with the consulting services business of 3M Health Information Systems.