According to the 2018 ICD 10 guidelines:
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, 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).
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, 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).
Does this mean that if polyneuropathy and vitamin B deficiency are documented in the same progress note, but not linked by the provider, I should still be coding them as linked?
Index has:
Polyneuropathy
in
->deficiency
–>B vitamins E53.9 [G63]
I know we do this for diabetes, but this scenario just doesn’t seem right to me.