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Documentation and Coding: Substance Use Disorders April 12, 2023 Claims & Coding

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.  Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.”

Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance use disorder is based on diagnostic criteria for the pattern of behaviors. Treating substance use disorder is challenging and varies depending on the substance and circumstances.

Documentation & Coding Tips 

Documentation needs to be clear and detailed using the following terms to allow accurate ICD-10 code selection.

Specificity:

  • Substance name
  • Type of disorder: use, abuse, dependence, withdrawal
  • Severity: mild, moderate, or severe
  • Status: current, in remission (partial or full)

Complications and/or associated conditions: Document & code the relationship between the substance disorder and any associated physical, mental, or behavioral disorder, such as...   

  • Intoxication, withdrawal, delirium, perceptual disturbance,
  • Mood, anxiety, sleep, sexual dysfunction, depressive, psychotic disorders,
  • Psychoactive substance withdrawal can occur in individuals who do not have a diagnosis of dependence but who use the substance regularly (i.e., use or abuse) and then reduce or cease the use.

Treatment:

  • Document treatment (medication, psychotherapy, or a combination of both) and current response to treatment.
  • Document any treatment refusals, or non-compliance.

Other:

  • If the provider documents use, abuse, and dependence of the same substance use the following hierarchy when coding.
DocumentationAssign Code
Both use & abuse documentedfor abuse
Both abuse & dependence documentedfor dependence
Use, abuse, & dependence all documentedfor dependence
Both use & dependence documentedfor dependence

ICD-10 

Description 

Drugs included 

F10.XXX 

Alcohol-related disorders 

 

F11.XXX 

Opioid-related disorders 

ex. heroin, methadone, oxycodone, hydrocodone 

F12.XXX 

Cannabis-related disorders 

 

F13.XXX 

Sedative, hypnotic, or anxiolytic-related disorders 

ex. Ativan, valium, Xanax, lorazepam 

F14.XXX 

Cocaine related disorders 

 

F15.XXX 

Other stimulant-related disorders 

ex. meth, Ritalin, Adderall, Dexedrine, bath salts 

F16.XXX 

Hallucinogen related disorders 

ex. LSD, PCP, ketamine 

F18.XXX 

Inhalant related disorders 

ex. glue, gas, sniff, whippets, rush, bolt 

F19.XXX 

Other psychoactive substance-related disorders (Inc. polysubstance drug use (indiscriminate drug use))