During our May 23, 2024 webinar regarding Substance Use, Abuse and Dependence, we received several important questions that we’d like to specifically address and hope you find helpful. The three questions are below followed by the answers.
Does Coding Clinic mention or address incorporation of DSM interpretations of Substance Use, Abuse and Dependence into ICD-10?
If the physician documents opioid dependence, do we code opioid dependence regardless if it’s prescribed or non-prescribed?
Does the clinician need to document "in remission" or is “history of” a substance use disorder enough to code "in remission" if it meets the definition of early or sustained?
Coding Clinic has included DSM (Diagnostic and Statistical Manual of Mental Disorders) definitions and criteria when new or revised ICD-10 codes are created for mental, behavioral and neurodevelopment disorders. For example, a 2017 Coding Clinic noted new inclusion terms have been added to the existing codes for substance dependence in remission and stated: “These inclusion terms harmonize with the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) clinical terminology and classifications to indicate substance use disorder in remission and severity.” Because of this close link between DSM and ICD-10, codes for substance use, abuse and dependence should be assigned in a way that is consistent with DSM-5 criteria and definitions.
It should also be noted that the collaboration and integration of DSM diagnostic definitions and criteria into ICD (International Classification of Diseases) goes back long before Coding Clinic was in existence.
Since 1948, the World Health Organization (WHO) has been responsible for the ICD and historically offered its own system of mental disorder classification. In 1982 there was worldwide agreement for the ICD to adopt more explicit diagnostic criteria to define mental disorders that adhered to the DSM developed by the American Psychiatric Association (APA). Since that time there has been a collaborative agreement between the APA and WHO for DSM to provide the diagnostic classification for mental disorders.
Although a 2013 Coding Clinic advises to assign a code for “drug dependence” for any type of drug dependency, prescribed or non-prescribed, a patient on prescription opioids or cannabis, for example, may not have a substance use disorder making “drug dependence” a clinically invalid diagnosis.
This 2013 Coding Clinic was in response to a question on how to code "opioid dependence with continuous use for chronic low back pain and sciatica." It also states that if the provider does not indicate drug dependence for continuous use of a prescribed narcotic, assign ICD-9 code V58.69, Long-term (current) use of other medications.
Since 2013, the diagnostic criteria regarding substance use disorders including dependence have been revised and are based on DSM. Although providers may document “opioid dependence” for a patient who is using opioids therapeutically and taking as prescribed, it would not be a clinically valid diagnosis if the patient does not meet the definition of a moderate or severe opioid use disorder. For a patient with opioid “dependence”, the patient’s use of the prescribed medication is uncontrolled to the point that their ability to function in day-to-day life becomes impaired. The DSM diagnostic criteria for a moderate or severe substance use disorder (i.e., dependence) requires meeting four or more problematic behaviors (as included in our webinar)—excluding tolerance and withdrawal.
As noted in DSM, symptoms of tolerance and withdrawal occurring during appropriate use of prescribed medications given as part of medical treatment (e.g., opioid analgesics, sedatives, stimulants) are not counted towards a diagnosis of substance use disorder.
Coding Clinic 2018 Second Quarter p. 11 and 2023 Third Quarter p. 18 address coding prescribed use of cannabis and opioids for chronic pain. In both, they advise not to report a code for psychoactive substance use when the substance is prescribed to treat a medical condition. However, Coding Clinic addresses provider documentation of “use” and not if the provider documented “dependence.”
As one of our attendees noted, “Coding a substance [use] disorder has massive implications for people including insurance discrimination...please be careful.”
The provider does not need to document “in remission” when “history of” a substance use disorder is documented. Based on the Official Coding Guidelines I.C.5.b.1: Selection of codes describing "in remission" for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use “requires the provider's clinical judgment and are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.”
The ICD-10 classification instructs, i.e., indexes, “history of” a substance use disorder to the ICD-10 codes for “in remission.”
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