Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term "with" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
A: I rarely teach physicians to use the term “with” as linking language because the term is very confusing. “With” can link two conditions together: for example, diabetes with gastroparesis or Alzheimer’s dementia with a behavioral disorder.
However, the term “with” cannot demonstrate cause and effect related to a complication, such as linking a urinary tract infection (UTI) to a Foley catheter. The documentation of UTI with Foley does not clearly indicate a cause and an effect—it merely communicates that the patient has both a Foley and a UTI. To create a link between the two, the provider would need to state “UTI due to indwelling Foley catheter.”
Other terms that could be used to show cause and effect are related to, secondary to, and associated with.
These terms will work to link two conditions, and will also suffice when identifying a complication and its underlying cause. My philosophy is keep it simple when it comes to provider education.
Editor’s note: Laurie Prescott, MSN, RN, CCDS, a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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