04.05.2024

Welcome. i am terri tropin and today i'll be. describing diagnosis and procedure. coding for substance use abuse and. dependence. but first let me start out with some. information about myself. i have a masters in healthcare. administration informatics from the. university of maryland global campus and. have rhia and ccsp certifications. i also am an ahima approved icd10. trainer. i taught health information technology. at montgomery college in maryland for. over 20 years. i've also written books on coding these. books are study guides that summarize. the coding guidelines my books include. one on e m coding one in icd10 cm. coding and one on. icd10-pcs coding. these are all available on amazon and. are updated every year or. as needed since sometimes they do. updates in the middle of. the year. okay so this is an overview of this.

Presentation. each of these will be discussed in. detail. what are psychoactive substance. where do you find these codes. what are some basic definitions used. with these codes what are some general. guidelines. how do you code for alcohol how do you. code for drug related how do you code. for nicotine how do you code for. inhalant. and then also some other diagnoses. outside the mental health. section that are used with these codes. and then. how do you find these codes in the. alphabetic index for cm. and also an overview of the. icd10 pcs codes used for treatment of. these conditions. substance abuse use and dependence are. referred to as use of psychoactive. substances. so what are psychoactive substances well. the mind. they act on the mind. they affect behavior. and may make a patient dependent if they. use too much over a long period of time.

So what are included in psychoactive. substances legal or illegal drugs. alcohol. nicotine. and inhalants each of these are going to. be discussed in this presentation. first i'm going to talk about diagnosis. codes. where are they found. well they're found in these areas of the. tabular list. alcohol disorders aren't f10. drugrelated disorders f11 to f16 since. there's a lot of different drugs and. types of drugs it takes more than just. one category. nicotine dependence f17 inhalant. disorders f18 and other psychiatric. psychoactive. substances disorders. and these are all in the mental health. section. so let's start with um. categories f10 fp19 substance use. what are some of the. how are the codes set up. well the codes in each category. are divided into subcategories use abuse. and dependence. now these. subcategories are further divided into.

Including digits for uncomplicated which. we're going to define in remission with. intoxication and with withdrawal. now in remission means they're not. currently using. with intoxication means the patient is. drunk or high at the time of the. encounter with the provider. with withdrawal means they've stopped. using the drugs and they're having. symptoms of withdrawal and we'll talk. about that a little more. also. so let's talk about use abuse and. dependence. how are these defined well use is the. patient uses the substance occasionally. for example a patient drinks heavily but. only on weekend only on saturday night. right to go to the bar have a lot to. drink that's use. abuse is the patient uses the substance. regularly even though it causes problems. in their life so this is occasional. this is regularly. but it's causing problems.

For example drinking is causing problems. in the patient's work life or. family life. dependence the patient is addicted to. the substance and has developed a. tolerance. patient will experience withdrawal. symptoms if he or she stops using the. substance and the best example of this. is. alcoholism. the categories for alcohol drug and. inhalant use abuse and dependence. include digits for uncomplicated with. intoxication and in remission so what do. these mean. uncomplicated means there's no. indication of the problem other than. drug use no documentation documented. intoxication delirium withdrawal anxiety. psychosis a related condition so if. nothing else is documented. another related condition is documented. we're going to use uncomplicated the. assumption is that if. intoxication delirium anxiety psychosis. etc were present the physician being a.

Good documenter would. have documented them so we're going to. assume it's uncomplicated unless there's. reason to believe otherwise. with intoxication patient is drunk or. high at the time of the encounter with. the provider. in remission patient no longer uses the. drug and is in recovery. these categories also include digits for. tolerance and withdrawal so let's talk. about what those means. tolerance is over time the body gets. used to a medicine or a substance that. either. more is needed in order to get the high. that they're looking for or they need to. change to a different probably stronger. medicine so their body is tolerance the. same amount of the drug will not get the. same high. withdrawal is when a patient quits using. a drug or alcohol and he or she will. experience symptoms such as nausea. vomiting diarrhea muscle bone pain etc.

May be used with codes for use abuse are. dependent it used to be that withdrawal. was assumed to be. only with dependents but they changed. the regs in the guidelines in a couple. years ago saying that a patient may use. or abuse the substance and still go. through. some kind of withdrawal. now alcohol drug and inhalant categories. note this does not include nicotine. include digits for delirium perceptual. disturbances psychotic. uh delusions. hallucinations mood disorders anxiety. sexual dysfunction sleep disorders. persisting amnesiac. disorder and persisting dementia. so let's define some of these terms i'm. a real stickler for. telling me what you're talking about to. find your terms. psychosis or psychotic disorder. the impairment of the mental state in. which the perception of reality has. become just uh distorted so they're not.

Seeing reality as it really is it might. be. seeing things hearing things paranoia. delusions changing the personality. disorganized thinking. hallucinations are hearing or feeling. things that aren't really there. delusions are false beliefs that. conflict with reality. okay here's some more. definitions. delirium is confused thinking and. reduced awareness of the environment. perceptual disturbance misinterpretation. of the environment. includes hallucinations and an inability. to judge the size or direction of. something. may include a flashback including. following use of a hallucinogenic drug. persistent. amnesic disorder lasting disturbance in. memory caused by. drug use. persisting dementia lasting. deterioration of mental functions. including impaired speech movement. sensory capabilities caused by the drug. use so these.

Persisting so they last over time. now for definitions for. nicotine use as you can imagine. not as much you're not going to get. hallucinations and psychosis from using. nicotine. so nicotine category f17 only includes. codes for dependence with digits for. uncomplicated in remission or withdrawal. now you are going to get some withdrawal. symptoms. i smoked for many years. i went through withdrawal. it was rough but. i made it so you are going to get. withdrawal but you're not going to get a. lot of the other things that you're. going to get with. other substances. so let's look at some general guidelines. for coding. for these conditions. so. the guidelines say assign a code for. psychoactive substance. based on provider documentation. okay. when this. that the physician or provider has to. say this is abuse this is dependence you.

Have to base your documentation on what. the provider has written down. you also will use these codes when the. substance use meets the definition of. reportable diagnosis. substance required clinical evaluation. treatment. diagnostic procedures extends the length. of hospital stay. and cause increased nursing care or. monitoring. and the provider must have documented. the substance use is associated with a. mental or behavioral disorder. so all of these. must be true. before you can use these codes. okay unfortunately sometimes the patient. may be abusing or dependent on more than. one substance the guidelines state that. code should be listed for each substance. involved. addiction or use of multiple substances. makes things much more complicated so. you want to have documented that. they're more than one. okay when do you use in remission we.

Defined in remission earlier as when the. patient is no longer using the drug and. is in recovery. so use in remission digits only if the. provider has documented that the. condition is in remission unless. otherwise instructed by guidelines or. notes now what's interesting is that you. have. codes for. mild substance use disorder in early or. sustained so short or long term. remission use the code for substance. abuse. and remission. if it's moderate or severe substance use. disorder in early or sustained remission. use a code for dependence with remission. so this is important. difference. withdrawal. we define withdrawal as the symptoms. that occur when a patient stops using a. substance. the guidelines state when a patient is. admitted for withdrawal symptoms list. first the code for withdrawal that's the. reason the patient is being admitted.

Now if the patient is being seen to. treat them to prevent withdrawal. symptoms that's not withdrawal. so only if they're actually in. withdrawal or being are admitted for. withdrawal. now sometimes a provider will document. use and abuse or abuse independence are. all three. so here are the guidelines. if the documentation states both use and. abuse list code for abuse only if the. documentation says abuse and dependence. list a code for our dependents only. both use and dependence list code for. dependence use of use independence list. code for dependence so what this is. saying is that. if they have both documented lists the. worst one if it says use and abuse code. for abuse because abuse is. more serious than use. if it's use independence or use abuse. independence you're going to code for. dependence because that's the more.

Serious one so. it's a long way of saying use the one. that's most serious only so only one. code. so the guidelines also cover the. circumstance when a medical condition is. present with use abuse or dependence. the medical condition is not coded as a. condition induced or caused by the. substance use this is kind of. counterintuitive so. this is interesting for example. alcohol pancreatitis due to alcohol. dependence now of course you're going to. do. the code for. alcohol. induce acute pancreatitis in the k. section but you're also going to do the. alcohol dependence is uncomplicated. the guidelines say don't use f10 288. which is alcohol dependence with. alcoholinduced disorder. so you're going to use this one as. uncomplicated even though this. pancreatitis was caused by. the. alcohol use. so. unspecified. is a digit 9 the fourth digit.

9. for these. these codes are not used at the. documentations says use or abuse. these are only used if it just says. alcohol or just says inhale it but. doesn't just doesn't further define it. as abuse art. dependence which depends it's. interesting. interest one of those autocorrect things. i guess. okay. use the the um. digit fourth digit nine with all of. these can f17 f16 f18 to f19. use only use only when the substance. used is associated with either a. substance related mental disorder so. there's a condition documented due to. the substance use. or if there's a medical condition but. remember. if it's abuse or dependence you're not. going to use these codes the 0.9 codes. so let's give it an example of that and. this will make it somewhat. clearer. so the patient is violent due to his. drinking but it's not. specified as use of user dependence.

The patient was intoxicated and. delirious when seen in the emergency. room. um so you would use. f10921 unspecified alcohol use and they. also code violent behavior probably the. violent behavior first because that's. what why they're being. admitted. now notice if it's specified as abuse. you wouldn't use the f10 921 you use f10. 121. if it's specified as dependence you. would code f 10.220. not f 10.921 so it's only if it doesn't. say use our views. okay so let's start at. alcohol. um you have this is f10 and you have use. or unspecified f 10.9 so we were just. talking about. abuse is f 10.1 dependence is f 10.2. so alcohol dependence may be documented. as alcoholism so alcohol dependence. equals alcoholism. okay. and here's some of the. signs and symptoms of. alcoholism alcohol dependence so this is. a chronic disease characterized by.

Strong compulsion to drink increased. tolerance which we just talked about. inability to stop when started and. physical dependence and withdrawal. symptoms. a note at the beginning of these codes. indicates that the blood alcohol level. level should be coded if known. these codes are in the external cause. chapter category y90. so if this is documented you would. report it but it's not necessarily. reported by the provider for example a. police officer. might record this at an accident scene. an ent might be documented at the. ambulance a nurse might document it at. the hospital. so it doesn't. if it's you have it it should be. coded. but you can accept a level by someone. other than the provider so these are in. the external cause. section. okay so let's do a practice. if you'd like to. do this on your own pause the video try.

To code it and come back and see what. we're talking about here. so alcoholism patient is drunk at the. time he is seen in the emergency room. so i would do f 10.229 although i can. see an argument for. other codes but we're going to say. because it's in the emergency room we. don't know if there's a complication or. delirium so we're just going to use. unspecified. okay the code is f 10.229 fifth digit. two indicates intoxication since the. patient was drunk at the time of. admission. after the patient is admitted. we will have more information. and be able to. do. abuse. use dependence whatever but right now. all we know is. patient is drunk. now there's an interesting note. alcohol. acute alcohol intoxication. may occur in patients do not have. chronic alcoholism this could be the. patient who goes out and gets. really really drunk.

Every weekend. okay and be seen in a facility with. intoxication that person is a user. but not uh does not have alcoholism. if the patient doesn't have chronic. alcoholism you would do a different code. okay so let's move on to drug use abuse. and dependence these codes are in six. different categories since there's so. many drugs that may be involved so you. have fl f11 opioid related disorders f12. cannabis related disorders f13 sedative. hypno. hypnotic or anxiolytic. related disorders. 14 cocaine and 15 other nf16. hallucinogen. so each codes in these categories has. digits for uncomplicated in remission. and withdrawal with intoxication and. with psychotic disorders. the third digit in the category changes. with the type of. drug so you can see here. here. and here this will change. um if it's used. are unspecified it has that that that.

Fourth digit nine if it's abuse is the. fourth digit one if it's dependent it's. fourth digit two. so it it will vary that third digit will. um vary with the kind of drug being used. okay so here's another practice patient. being treated for withdrawal due to. dependence on valium a sedative. sometimes you have to kind of google to. find out what the medication is if. you're not familiar with it this is a. sedative there's no indication of. complications due to withdrawal at this. time. okay if you'd like to do this on your. own. pause the video and come back when. you're ready. okay so this is f 13.2. the alphabetic entry is dependence drug. sedative with withdrawal. the fourth digit. 2 indicates dependence. here. the fifth digit three indicates. withdrawal. the final digit zero indicates. uncomplicated. so all of this is incorporated into.

The code. so we're going to say it's uncomplicated. there's no other possible conditions. delirium perceptual disturbances other. things documented so this is a. uncomplicated. here's another practice. patient is in remission for dependence. on oxycodone and opioid patient has not. used the drug in 18 months. it if you wish. okay the code is f11.21. the alphabetic index entry is dependence. drug opioid in remission the fourth. digit two. is dependent. fifth digit one. remission. so let's move on to nicotine related. disorders these are not as complicated. um because you're not going to have a. psychosis or hallucinations because of. smoking. nicotine anyway. codes for nicotine dependence on. different codes for cigarettes chewing. tobacco and other substances such as. electronic cigarettes this is category. f17. also specific codes for dependence that.

Is uncomplicated in remission and in. withdrawal. now there are also codes and we're going. to talk about these more later in the. z code section. history of tobacco use. and then tobacco used without dependence. so this is the one. i've known friends i don't know how they. can do it who always smoke at parties or. only smoke when they're when they're. drinking and they're fine with that they. don't have any trouble with that not. anybody can do that but. some people can. okay so here's another practice pause if. you wish. the patient is addicted to chewing. tobacco uncomplicated patient is. currently using the drug. so the code is f 17.220. and the alphabetic index look at. dependence drug nicotine chewing tobacco. uncomplicated. the fifth digit two. indicates chewing tobacco the final. digit zero indicates uncomplicated.

Meaning not in remission not in. withdrawal so it's uncomplicated. okay finally we come to inhalant. disorders. these are the f 18 category you have. used in unspecified f 18.9 abuse f 18.1. dependence f 18.2. there are also codes for abuse our. dependence that is uncomplicated in. remission and withdrawal with. intoxication and with psychotic. disorders. so kim what are inhalants what inhalants. are chemicals found in ordinary. household or workplace products. are that are inhaled. deliberately. in order to get high. for example. paint thinner nail polish remover. gasoline correction fluid glue like. airplane glue so here's a list of those. easy stuff to get it's easy in the house. but. quite deadly. okay here's a final practice. patient abuses glue he's exhibiting. psychosis with the hallucinations as a. result. okay the category the code is f 18.151.

The fourth digit is. one. for abuse fifth digit is five. for psychotic disorder and the sixth. digit is one for hallucinations so we're. going to look this up as abuse drug. inhalant with psychosis hallucinations. so here are some related codes in other. sections um encounter for blood alcohol. and blood. blood drug tests 03.83. these are all in the z code section. alcohol abuse counseling and. surveillance see 71.5 with additional. digits tobacco use counseling c71.6. tobacco use the patient is currently. using. d70 z72.0. long term current use of opioid opiate. and. analgesic such as methadone maintenance. is z79.891. you have personal history of nicotine. dependence. i got that one oh it's been over 35. years. family history of alcohol abuse and drug. abuse unfortunately there is often a um. hereditary component. with these so it's important to know if.

There's a family history. now note that z. 72.0 is used for tobacco use this is for. patients who use tobacco but are not. addicted. 87.891 is used for patients with history. of dependence. if you look up history personal alcohol. dependence you're referred not to a z. code but to f10. if you look up history personal drug. drug dependence you're referred to. dependence drug in remission codes f11. to f16. if you look up history substance abuse. nec you're referred to f10 to f19. why is this well this is because. dependence is considered to never be. really cured and will always be in. remission tobacco use. is uh. different. that will have a z code. but the alcohol. drug and inhalant will take you back to. the mental health. chapter which is kind of interesting. sometimes the hardest part of coding is. finding the entry in the alphabetic.

Index here are some entries for these. codes you can look up abuse. alcoholism dependence use you can also. look up alcoholism alcohol alcoholic. alcoholic induced. you can look up intoxication you can. look up tobacco and under each of these. there will be entries for. the different types of. abuse. dependence. disorder. and use. now remember that alcoholism. is dependence. okay now let's move on to the icd10 pcs. coding for substance abuse treatments. now these codes are in the ancillary. section of your pcs book they're not in. the main part of the book the surgery. section. so we have all of these codes we give. them h for substance abuse treatment the. second. character. will always be a z for none. the type of service is a character that. will vary. the third digit the fourth character. also will vary but everything else five.

Six seven is a z so these are like. placeholders because you have to have. seven digits so just. put in. a z. so in the ancillary section near the. back. first character is always h substance. abuse treatment the second character the. body system always is a z the third. character will be the type of substance. abuse procedure or service so you have. two for detox services three for. individual counseling for for group. counseling five for individual. psychotherapy. six for family counseling eight for. medication management and nine for uh. pharmacotherapy. okay so what's the difference between. medication management and. pharmacotherapy. medication management. character eight is monitored and. ingested replacement medications for. treatment of an addiction for example. monitoring dosage of methadone used to. treat patients dependent on.

Heroin is the dosage correct is it. working are there too many side effects. etc. pharmacotherapy. character nine is more longterm. this is. with a to wean the patient from the. um. substance. so for an example patient receives. methadone as point a longterm methadone. maintenance treatment for heroin. dependence so that's kind of a. if it's just monitoring the dosage it's. an eight if it's more longterm. um to wean the patient from the. substance it's pharmacotherapy. so that was the third digits the fourth. digits. indicate more information about the type. of service being. provided. so far. third character counseling three and. four and psychotherapy. character five these will have the. fourth characters such as. cognitive behavioral 12step vocational. okay this will further clarify what kind. of counseling what kind of psychotherapy.

Now for medication management and. pharmacotherapy. they use the fourth digits such as. nicotine replacement methadone. maintenance and an abuse. so it further defines the medication the. medication being managed are the therapy. pharmacotherapy type of pharmacotherapy. being. used. okay sometimes other types of service. the character three list only one option. for um. character four so. for the type of service character three. detoxification. uses only a fourth character. z. the type of service for family. counseling uses only fourth character. other family counseling and all other. cases of course the fifth and through. seventh digits are z none so most of. these are pretty straightforward you. only have to worry about a couple of. different characters. for example detoxification from alcohol. and or other drugs. h72zz.

So the only ones that are different are. detox. and everything else. is the same. for family counseling the code is h. h z six three z z z so the only. characters that change are. these two family counseling other family. counseling. and the other family counseling is the. only option for. uh family counseling so it's kind of. redundant. rehabilitation is a another. factor. rehabilitation there's no specific codes. for this because it can take many forms. it can be counseling it can be family. counseling group fam counseling. it can be psychotherapy combined with. counseling pharmacotherapy detox. services. code for was actually provided in a. specific case now you may be saying hey. wait a minute there's a whole section on. rehabilitation that's for. rehabilitation and audiology. that's a whole different thing that's.

Physical. rehabilitation that's the patient who is. recovering. getting therapeutic therapy for um. an injury so that's not the same as. death. okay it is impossible to remember all. the guidelines for these codes or for. any. section so here's the suggestions of. notes to make in your book. for your this is for your icd10. cm book. so code the note in the guidelines about. coding for documentation use abuse and. dependence for the same patient so just. code that circle that. in the alphabetic index find history. personal. and code that circle the notes about. coding for history of drug dependence. alcohol dependence and substance abuse. and the tabular list of your book the. beginning of the chapter note writing. the definition of intoxication. and any other definitions that you think. you need to remember that you might not.

Remember so just write them in your book. and they'll be right there. and find f10 alcohol related disorders. and circle the note about coding also. blood alcohol level. so what about in your pcs book you might. make a note about the difference between. medication management and. pharmacotherapy. and make a note also about rehab. services and code what was actually. performed don't use the rehabilitation. section. this completes the video if you have. questions. or comments please feel free to contact. me. if you would like to purchase purchase a. copy of the slides for this video. contact me at terry.tropin gmail.com. if you enjoyed the video please give it. a like or subscribe and subscribe. by clicking on the picture in the lower. right hand corner. again here are the books that i have. written. e m coding. sam pcs here's the link.

to these on amazon these are updated. every year or as needed. thank you very much. i hope you enjoyed this video. thank you