Know the True Meaning of ‘With’ in the ICD-10-CM Alphabetic Index
Question: I work for a cardiology office and reviewed a progress note for a patient with hypertension and heart disease. The cardiologist lists both conditions in the assessment but does not explicitly say the heart disease is “due to” or “caused by” the hypertension. When I checked the ICD-10-CM Alphabetic Index to find the appropriate codes, I saw an entry for hypertension “with” heart involvement. Should I report this with a single code even though the provider diagnosed two conditions? Virginia Subscriber Answer: Remember that in the realm of ICD-10-CM, some words carry particular meanings beyond conversational English. The term “with” in the Alphabetic Index means “associated with” or “due to,” and it creates a presumed causal relationship between the listed conditions — unless the documentation clearly states the conditions are unrelated. For cardiology coding, this rule is especially important when reporting conditions like hypertensive heart disease or some vascular and circulatory manifestations. Generally, coders are trained not to assume clinical relationships that the provider does not document. However, the ICD-10-CM “with” convention is an exception that coders need to navigate with confidence, as the classification presumes the linkage. If the Alphabetic Index supports a “with” relationship, you shouldn’t ignore that relationship between the conditions, even if the provider did not use words such as “caused by,” “secondary to,” or “due to.” Failing to apply the “with” convention can lead to undercoding when a valid combination or manifestation code is available. Applying it inconsistently can also create audit risk because similar documentation may be coded differently from encounter to encounter. You can trust the Alphabetic Index relationship unless the record clearly contradicts it or another guideline requires explicit linkage; the ICD-10-CM guideline overrides coders’ usual “don’t assume” instinct when the “with” convention applies. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
