Q&A: Identifying etiology/manifestation vs. complication connections

Q: We recently had a case where the patient was admitted for “sepsis secondary to a urinary infection (UTI) with chronic Foley.”  I am wondering if there is a AHA Coding Clinic for ICD-9-CM  to support coding this case to 996.64, Infection and inflammatory reaction due to indwelling urinary catheter? Or does this need additional clarification?

A few of our physicians say it is perfectly clear that the Foley is the cause of it all, but our coders insist the documentation must say “due to” for them to link the two. I have not seen any rule to this regard, however. I feel stuck in a stalemate between the coders and the physicians and it is a similar situation with “chest pain with coronary artery disease (CAD).”

A: So much of coding is subjective.  I can see where the coder may want stronger documentation of the relationship between the chronic Foley and sepsis and/or the UTI as I’ve seen denials for code 996.64 based on similar documentation.

That said, the phrase “due to” isn’t the only verbiage available to the physician to identify a linkage between two diagnoses. In fact, the Official Guidelines for Coding and Reporting state that the words “with” can mean “due to” or “associated with.”

Usually, the term “with” is sufficient to “link” two diagnoses if they are part of an etiology/manifestation pair (where one condition causes another or to use a combination code)—just not in this situation. Here, we are using a complication code so we must also consider the Guidelines associated with the use of such codes.

The problem with this particular situation is that the provider only notes the chronic Foley, not that the Foley is the cause of the UTI.  The Guidelines (I. B. 18.) state:

“There must be a cause and effect relationship . . . and an indication in the documentation that it is a complication.”

The term “with” just implies coexistence, not a cause and effect relationship. The provider could document “UTI from chronic Foley use,” or “UTI secondary to chronic Foley,” or “UTI associated with chronic Foley use,”  etc.  I can see the provider’s viewpoint, but in this situation the Guidelines protect the provider from a coder inadvertently using a complication code, which is why the documentation of the cause-and-effect relationship needs to be clear.

Chest pain and CAD is a different scenario because it is not a complication code. So the provider can state, “chest pain with CAD.” Coding Clinic for ICD-9-CM, Second Quarter, 1997 and Third Quarter, 2001, do allow CAD to be the principal diagnosis with angina, but most extrapolate this guidance to chest pain. This is a classic CDI strategy to move a case out of the chest pain DRG and into the arthrosclerosis (CAD) DRG.

CDI specialists need to query the provider if the patient has a history of CAD to see if there is a relationship between the CAD and chest pain. Use of the word “with” in this case is demonstrating an etiology/manifestation relationship between these two diagnoses, neither of which are a complication code.  In ICD-10-CM there is going to be an assumed relationship between CAD and angina allowing use of a combination code so a query will no longer be required.

Best of luck with the providers, but if you let them know that it is for their profile benefit, it might make them a little more agreeable.