Psychoactive Substance Use – Revisited

Cathie Wilde, RHIA, CCS - Director, Coding Services Medical Coding Leave a Comment

Psychoactive Substance Use – Revisited

Mental, behavioral and neurodevelopment disorders located in Chapter 5 of the ICD-10-CM Coding Manual were first addressed in the August 10, 2021, MRA Blog (https://www.mrahis.com/blog/chapter-5-coding). Here, we will be specifically discussing the mental and behavioral disorders related to psychoactive substance use which are included in Chapter 5.

 

Alcohol and substance intake has increased over the past year or so, likely representing a misdirected attempt to find comfort in this time of uncertainty and adversity. Unfortunately, excessive use has resulted in further distress and complications for patients.

 

Category F10 classifies alcohol-related disorders with F10.1- designated for alcohol abuse and F10.2- for alcohol dependence. The category further addresses remission status, intoxication, withdrawal, alcohol-induced mood disorder, alcohol-induced psychotic disorder, and other alcohol-induced disorders. Abuse has been defined as problematic recurrent use of alcohol despite negative consequences while dependence includes the presence of symptoms such as tolerance, withdrawal, and reduction of social, occupational, and recreational pursuits due to alcohol use.

 

In 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) combined alcohol dependence and alcohol abuse into one diagnosis of alcohol use disorder with mild, moderate, and severe sub-classifications. Sometimes this causes confusion if the psychiatrist establishes and documents the diagnosis based on DSM-5. When coding and billing accounts, code assignment is based on ICD-10-CM and not DSM-5. DSM-5 is primarily a nomenclature used by psychiatrists for criteria in diagnosing and treating mental disorders while ICD-10-CM is used for reimbursement purposes and monitoring of morbidity/mortality statistics.

 

Alcohol use without specification of abuse or dependence is assigned to F10.9- but only if the provider documents a relationship between its use and an associated physical, mental, or behavioral disorder. If alcohol use is documented without further specification, it is to be coded to Z72.89, Other problems related to lifestyle. However, if there is documentation of alcohol use (not specified as abuse or dependence) with intoxication, sleep disorder, or withdrawal, code assignment is to F10.9-. If alcohol use is documented as “harmful”, it is assigned to alcohol abuse.

 

Category Y90, Evidence of alcohol involvement determined by blood alcohol level (BAL) may be assigned when the provider has documented a condition classifiable to category F10. The BAL itself does not need to be documented by the physician for it to be coded; it is one of the exceptions whereby it may be documented by a clinician who is not the patient’s provider (OCG I.B.14.).

 

Patients who are potentially in alcohol withdrawal or suspected to develop alcohol withdrawal are often assessed using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale. CIWA is a ten-item objective and efficient scale used for assessment and management of alcohol withdrawal. The symptoms evaluated and scored include nausea and vomiting, tremor, anxiety, agitation, and headache (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597013/)

 

Substance use codes have a similar classification as alcohol with abuse and dependence codes which are further identified by remission status, intoxication, withdrawal, drug-induced mood disorder, drug-induced psychotic disorder, and other drug-induced disorders. There are different drug categories according to class of drugs:

 

F11         Opioid related disorders

F12         Cannabis related disorders

F13         Sedative, hypnotic or anxiolytic related disorders

F14         Cocaine related disorders

F15         Other stimulant related disorders

F16         Hallucinogen related disorders

F17         Nicotine dependence

F18         Inhalant related disorders

F19         Other psychoactive substance related disorders

 

Unlike a diagnosis of alcohol use without further specification, there are codes for substance use without additional description; these are assigned to fourth character “9” and fifth character “0” for use, unspecified, uncomplicated (e.g., F10.90 inhalant use, unspecified, uncomplicated).

 

For both alcohol and substance use, the fourth character “1” indicates abuse while fourth character “2” indicates dependence in most cases. Additional characters then specify intoxication, delirium, perceptual disturbances, mood disorder, psychotic disorder, withdrawal, and other-substance induced disorders such as sexual dysfunction or sleep disorder.

 

Withdrawal usually occurs when there is an abrupt discontinuation of the substance or a substantial decrease in its use. Previously, it was thought withdrawal only occurred in patients with substance dependence, but it can occur with use and abuse; the codes currently reflect this change. Symptoms often vary from individual to individual and substance to substance. Some of those symptoms include agitation, anorexia, sleep disturbance, seizures, and hallucinations. A severe form of withdrawal called delirium tremens is characterized by symptoms such as fever, tachycardia, hypertension or hypotension and confusion.

 

Medical conditions may occur as a direct result of psychoactive substance use, abuse, and dependence. Some common examples are pancreatitis, hepatitis, cirrhosis, and neuropathy. Assign the code for the medical condition as directed by the Alphabetic Index as well as the appropriate substance use code. Sequencing will depend on the circumstances of the admission.

 

The inclusion terms in the Tabular List designate substance abuse codes indicative of mild use while codes for dependence are indicative of moderate and severe use. Codes for “in remission” status are only to be coded based on provider documentation.

 

The Official Coding Guidelines have established a hierarchy for code assignment when provider documentation refers to use, abuse, and dependence within the record (OCG I.C.5.b.2.). Only one code should be assigned for the substance use based on the following:

 

  • If both use and abuse are documented, assign only the code for abuse
  • If both abuse and dependence are documented, assign only the code for dependence
  • If use, abuse and dependence are all documented, assign only the code for dependence
  • If both use and dependence are documented, assign only the code for dependence

Leave a Reply

Your email address will not be published. Required fields are marked *

Sign Up For MRA Blog Updates!

Recent Posts