ICD-10-CM WITH guideline explained: Essential tips for clinical coders

In medical coding, accuracy is everything. The ICD-10-CM WITH guideline plays a critical role in linking conditions correctly and ensuring compliance. Understanding this rule helps clinical coders avoid costly errors and maintain reporting integrity.
 

What does “WITH” mean in ICD-10-CM?

According to the ICD-10-CM Official Guidelines, Section I.A.15, the term “with” (or “in”) means “associated with” or “due to” when it appears in:

• A code title
• The Alphabetic Index (under a main term or subterm)
• Instructional notes in the Tabular List

This convention presumes a causal relationship between conditions unless documentation clearly states otherwise. The classification presumes a causal relationship between the two conditions unless the documentation clearly states otherwise or another guideline requires explicit linkage (e.g., sepsis with organ dysfunction).
 

Where the WITH guideline applies

The WITH rule appears throughout ICD-10-CM:

• Alphabetic Index: Subterms after “with” follow the main term.
• Tabular List: Combination codes often reflect linked conditions.
   

Common examples of the rule in action

One of the most common and well-known examples is the presumed relationship between hypertension and both chronic renal failure and heart failure. Other common diagnoses that have “WITH” index entries (and therefore presumed causal relationships) include diabetes with most manifestations and respiratory failure with hypoxia and/or hypercapnia. 

It is important to note that while hypertension and chronic kidney disease commonly occur together, there are instances where the “WITH” guideline does not apply. Coding Clinic, Third Quarter, 2016, page 22–23 provides a vignette. The patient has diagnoses of end stage renal disease due (ESRD) to congenital polycystic kidney disease as well as hypertension. Because the clinician has specifically stated that the ESRD was caused by or due to polycystic kidney disease, the appropriate code assignment is I15.1-Hypertension secondary to other renal disorders and not I12.0-Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease.  

Another example where the “WITH” guideline does not apply is for index entries of “not elsewhere classified (NEC).”  Coding Clinic, Fourth Quarter, 2017, page 100–101 reinforces this guidance with an example of a patient that has both cellulitis and diabetes. There is an index entry for diabetes, with skin complications NEC; however, there is not an index entry for diabetes; with cellulitis. Therefore, we cannot assume the causal relationship and must seek clarification from the provider if the cause of the cellulitis is not clear in the documentation. 

Less well-known WITH index entries include Obesity; with alveolar hypoventilation and Influenza; with gastroenteritis. There are hundreds of examples of this convention throughout both the index and tabular sections of the codebook. It is imperative that coders use and follow the index guidance and verify in the tabular. Reference section I.B.1 of the ICD-10-CM Official Guidelines for Coding and Reporting.  
 

Key coding rules and exceptions

• Presumed linkage: Assume conditions are related unless documentation negates it.
• Override by documentation: Follow provider notes if they state conditions are unrelated.
• Guideline-specific exceptions: Some chapters (e.g., sepsis) require explicit linkage.
   

Practical tips for coders

• Start with the Alphabetic Index to identify linked terms.
• Verify in the Tabular List for code structure; laterality and any required 7th characters.
• Use combination codes when they fully describe the condition.
• Query when in doubt — ask the provider for clarification.
• Avoid overcoding — don’t assign multiple codes when one combination code suffices.
   

Conclusion

The ICD-10-CM WITH guideline is more than a word; it’s a coding convention that impacts accuracy and compliance. By applying it correctly, coders can ensure precise reporting for data collection.

Teresa Seville, RHIT, CCS, is a development analyst at Solventum.