Q&A: “With” as a linking term

Q: A question came up with our staff regarding if we should be querying for linking terms using the term “with” such as “Foley with UTI.” Is the documentation of “Foley with UTI” appropriate to indicate a catheter-associated urinary tract infection (CAUTI) when not present on admission since the word “with” assumes a relationship between the two terms as outlined in the Official Guidelines for Coding and Reporting?

A: The word “with” has caused a few misconceptions over the years in clinical documentation so let’s turn to the actual verbiage of the Official Guidelines for Coding and Reporting, Section 1.A.15:

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 sub-term), 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 sub-term, not in alphabetical order.

In order to decipher the language above, let’s look at how the guideline begins by stating: “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 sub-term), or an instructional note in the Tabular List.” (Emphasis added.)

What’s often overlooked regarding the “presumed linkage” between two terms using the word “with” is that the presumed linkage is dependent on the condition having an entry within a code title, Alphabetical Index or Tabular List, not provider documentation. It’s only when “with” is listed within these three areas above that the term means “associated with or due to.”

If a provider documents, “UTI with Foley,” it is not enough to extrapolate out a cause-and-effect relationship using “with” as a linking term because the term “UTI” does not have the term “with” listed in the code title, Alphabetic Index, or the Tabular List. Therefore, the provider must link the two terms to illustrate cause and effect relationship.

Additionally, when one reads “UTI with foley,” does that statement imply that the UTI was caused by the Foley or that the patient has a UTI and a foley is present? It’s difficult to know what the provider’s intent is with this statement. Therefore, it’s best to educate providers to use linking language such as associated with, due to, caused by, secondary to, etc. when documenting a cause-and-effect relationship.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.