A diabetic patient is admitted with gangrene. The physician does not specifically link the diabetes and the gangrene, but alsodoes not document any other potential cause of the gangrene. Should you code both conditions?
In ICD-9-CM, coders can assume a cause-and-effect relationship between the diabetes and the gangrene as long as the physician does not document any other causes of the gangrene (Coding Clinic, First Quarter 2004, pp. 14-15).
That guidance allows coders to report the gangrene, which is a CC, even if the physician does not state that the gangrene is due to diabetes. "Physicians are not always good at documenting cause-and-effect relationships," says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, senior coding instructor for HCPro, a division of BLR, in Danvers, Massachusetts.