CKD and anemia

We had an issue come up today and I would appreciate any help.  
Pt presents w/ anemia, hgb 4.8, symptomatic. transfused, had EGD no findings, + fecal occult blood.  Doing colonoscopy as outpt. per her request.  Pt has HTN and CKD stage 3.  I coded the anemia as PDX since focus of care. Our coder states that anemia is auto linked to CKD? I agree that if the documentation states anemia in, d/t, with CKD then yes I would link them. This record calls it normocytic anemia and never links the conditions. As we were talking about it she explained that when you type anemia in encoder number 7 says in(due to)(with) (eg. chronic kidney disease), therefore a link is provided. 
I have never had this come up before. Any information is appreciated.
Amy Fenton RN CDI 
Bronson Healthcare Group
Kalamazoo MI


  • Hi Amy,

    The way I understand the guideline for “with” and “in”, they follow the same rule and do not have to have specific provider documentation linking the two conditions.  I've always found the index a bit confusing though, with how some terms are listed under “with” and some or listed under “in”.   Also, the AHA Coding Handbook, even though this is not considered official coding guidance, gives the same instruction and uses Anemia in Chronic Kidney Disease as an example.

     Conventions for ICD-10-CM

    ICD-10-CM Official Guidelines for Coding and Reporting

    Effective October 1, 2019 - September 30, 2020

    Section I. Conventions, general coding guidelines and chapter specific guidelines

    The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated.  The instructions and conventions of the classification take precedence over guidelines.

    A. Conventions for the ICD-10-CM

    The conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes.

    15. "With"

    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 subterm), 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.


    AHA Coding Handbook

    Chapter 3: ICD-10-CM Conventions

    The following example from the Alphabetic Index for the main term Anemia and the subterm "in" demonstrates the linkage between conditions:

    •Anemia (essential) (general) (hemoglobin deficiency) (infantile) (primary) (profound) D64.9

    •-in (due to) (with)

    •--chronic kidney disease D63.1

    •--end stage renal disease D63.1

    •--failure, kidney (renal) D63.1

    •--neoplastic disease (see also Neoplasm) D63.0

    The diagnoses of anemia and chronic kidney disease are coded as D63.1, Anemia in chronic kidney disease. This linkage can be assumed because the chronic kidney disease is listed under the subterm "in (due to) (with)."

    Laura Hoot RHIT, CCS, ACDIS CDI Apprentice

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