Notes from the Auditor’s Desk: Coding Drug Use

This is the first in a series of blogs that will highlight some of the most common coding errors encountered while auditing.

A frequent error is coding "use" of drugs (for example, “cannabis use”, “cocaine use”, etc.) without an associated condition/disorder diagnosis.  Per coding guidelines, documentation of drug use (other than a prescribed drug) or alcohol use cannot be coded “unless an associated physical or mental condition is also documented."

From Chapter 15 Guidelines:

Psychoactive Substance Use

“In addition to the codes for psychoactive substance abuse and dependence, ICD-10-CM provides codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-). As with all other diagnoses, these codes should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis per Section III, Reporting Additional Diagnoses, of the ICD-10-CM Official Guidelines for Coding and Reporting. The codes are to be used only when the psychoactive substance use is associated with a substance-related chapter 5 disorder or a mental or behavioral disorder or medical condition and such a relationship is documented by the provider. A "substance-related chapter 5 disorder" refers to conditions such as sexual dysfunction and sleep disorder that are not mental disorders but are included in chapter 5.

Alcohol withdrawal occurs in alcohol dependence and alcohol abuse, but it may also develop in patients with patterns of use that are not described as dependence or abuse. Codes F10.930, Alcohol use, unspecified with withdrawal, uncomplicated; F10.931, Alcohol use, unspecified with withdrawal delirium; F10.932, Alcohol use, unspecified with withdrawal with perceptual disturbance; and F10.939, Alcohol use, unspecified with withdrawal, unspecified, are assigned for withdrawal symptoms in alcohol use.”

 Additional clarification in Coding Clinic states:

 Psychoactive substance use and physical disorder

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2020 Page: 9 Effective with discharges: March 5, 2020

“Question:

The Official Guidelines for Coding and Reporting for Psychoactive Substance Use, Unspecified (I.C.5.b.3.) state, ‘These codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.’ Coding professionals are unclear as to what constitutes a ‘physical disorder.’ What does the term ‘physical’ in guideline I.C.5.b.3 mean?

Answer:

Effective October 1, 2018, the guideline for psychoactive substance use, unspecified, (categories F10-F19 with fourth character 9) was revised and the term ‘physical’ was added, to capture specific problems, such as sexual dysfunction and sleep disorder, included in the chapter 5 codes that are not mental disorders. This guideline revision was not intended to suggest other conditions would be classified as physical disorders when associated with substance use, abuse and/or dependence.”

For example, cannabis hyperemesis syndrome would be an associated condition related to drug use, so this could be coded as such. Another example would be if a pregnant woman is documented as taking illegal drugs (not prescribed to her) while pregnant. This would be considered an associated condition affecting the pregnancy, unless the physician stated otherwise.

For alcohol use, terms such as "alcohol use with: anxiety disorder/mood disorder/psychotic disorder/anxiety disorder" or other specified disorder, should be documented in order to assign a code from subcategory F10.9, Alcohol use. This would also include "withdrawal" and/or "intoxication"; i.e. "alcohol use with withdrawal", as this is considered an associated condition.

Also for alcohol use, a misleading term often encountered is alcohol use disorder, because this appears to be an associated disorder or condition. This terminology of “use disorder” was introduced into ICD-10-CM to align the classification with the DSM-5 clinical terminology, and it is carried throughout the psychoactive substance use block of Chapter 5.

Alcohol use disorders can be coded only IF the severity level is documented. These are mild, moderate and severe. Mild alcohol use disorder is coded to subcategory F10.1, alcohol abuse. The documentation should state either alcohol abuse or alcohol use disorder mild, in order to assign a code for alcohol abuse.

Alcohol use disorder moderate or severe is coded as alcohol dependence. In the ICD-10-CM classification, the inclusion terms under code F10.20, alcohol dependence, uncomplicated, are "alcohol use disorder, moderate" and "alcohol use disorder, severe". One of those two levels of severity should be documented along with the term "alcohol use disorder" to correctly code alcohol dependence. That term is not to be used to code "alcohol use" per the information above.

If multiple levels of use disorder are documented, only code the highest level. For example, if abuse (mild) and dependence (moderate or severe) are both documented, code only dependence.

As with all coding guidance, it must be applied with an accurate interpretation of the documentation. There may also be facility-specific coding policies to consider, but this is a great starting point for understanding the codes describing drug use.

Hobert Hampton, RHIT, CCS

Quality Assurance Analyst