Linking for CDI and Coding

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Linking conditions creates a causal relationship between two conditions or the condition and its etiology.  Documentation of linkage is important clinically and to properly specify and clarify conditions with causes.

Linking Terms

  • In
  • With
  • Due to
  • Associated with

To ensure appropriate coding and capture of risk, providers should link related conditions using terms such as “due to” or “associated with.” However, coding guidelines deem certain conditions to be automatically linked whether or not the provider links the condition in the clinical documentation. These conditions will be captured as related unless the provider specifically states the conditions are unrelated or another guideline exists that requires documented linkage for the two conditions.

Examples of conditions assumed to be related include:

  • Pneumonia and Aspiration
  • Gastric Ulcer and GI bleeding
  • Hypertension and Heart Disease

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