Coding hierarchy of Use, Abuse and dependence

The terms use, abuse and dependence are used frequently and sometimes interchangeably when we talk about alcohol and drugs. Understanding the differences of these terms and the coding hierarchy will help coders to assign the correct codes. You can take away some useful hints from this article to code encounters related to use, abuse and dependence cases.

Let’s see the basic definition of all these terms as below:

Use: It refers to any consumption of a substance (alcohol or drug) on a regular basis to alter his mood or emotional feelings. No obvious clinical manifestations are seen at this level.

Abuse: It describes the habitual consumption of drugs or alcohol even when it causes problems in their lifestyle such as trouble with work, family or health and not taken for any therapeutic purposes. Clinical manifestations are evident as signs and symptoms develop.

Dependence: It indicates the patient’s compulsive and continuous consumption of a substance resulting in significant clinical manifestations as well as a physiological need to have the drug for normal function. To diagnose dependence, the following criteria must be met:

  • Development of tolerance to the drug.
  • Consumption of more of the drug than intended.
  • Experiencing withdrawal symptoms upon cessation of the drug
  • Inability to stop the usage of the drug

Key points to select psychoactive substance use disorder codes:

1. Dependence vs Abuse vs Use – coding hierarchy

2. Type of psychoactive substance: Alcohol or Drugs or nicotine

3. Associated complications

4. Lifestyle issues, if applicable

5. Psychoactive substance use in Pregnancy cases

1. Dependence, Abuse and use:

Per ICD-10-CM Coding Guidelines, when the provider documentation refers to use, abuse and dependence of the same substance (e.g., alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern based on the following hierarchy:

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

2. Type of psychoactive substance: Alcohol or Drugs or nicotine

ICD-10-CM provides the below categories for the substance use disorders of alcohol, drugs and nicotine.

The categories for alcohol (F10) and drugs (F11-F16; F18-F19) are further classified based on the dependence, abuse and use with associated complications. However ICD10-CM classifies nicotine dependence by the substance used and the patient’s dependence as below:

ICD-10-CM classifies nicotine dependence by substance:

  • F17.20-, nicotine dependence, unspecified
  • F17.21-, nicotine dependence, cigarettes
  • F17.22-, nicotine dependence, chewing tobacco
  • F17.29-, nicotine dependence, other tobacco product

Each category further breaks down the dependence using a sixth character to denote:

  • 0 Uncomplicated
  • 1 In remission
  • 3 With withdrawal
  • 8 With other nicotine-induced disorders
  • 9 With unspecified nicotine-induced disorder

3. Associated complications:

Alcohol related disorders are classified to category F10. An additional code for blood alcohol level (Y90) may be assigned if applicable. When the alcohol use is not specified as dependent or abuse, you need to report F10.9 series which states Alcohol Use, unspecified.

Both categories of alcohol abuse and alcohol dependence are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder with delusions and hallucinations, dementia, anxiety, sexual dysfunction and sleep disorder. The provider must document if the patient has any associated complications to select the appropriate codes.

Drugs related disorders are classified to F11-, F12-, F13-, F14-, F15-, F16-, F18 and F19. In most of the cases, the fourth character indicates the disorder as abuse, dependence and unspecified use. Additional characters are provided to specify the complication as intoxication, intoxication delirium, intoxication with perceptual disturbance, drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).

4. Lifestyle issues, if applicable:

Code category Z72 classifies to Problems related to lifestyle. Code Z72.0 is for tobacco use and the most common lifestyle problems of tobacco use would include:

  • Education and/or literacy problems
  • Employment problems
  • Life management difficulty
  • Occupational exposure to risk factors
  • Problems with housing/economic circumstances
  • Problems with family
  • Psychosocial problems
  • Social environment problems

5. Psychoactive substance use in Pregnancy cases:

Codes under subcategory 099.32 Drug use complicating pregnancy, childbirth, and the puerperium should be used when a mother uses drugs during the pregnancy or postpartum. This can involve illegal drugs, or inappropriate use or abuse of prescription drugs. A secondary code from categories F11-F16 and F18-F19 should also be assigned to identify the manifestations of the drug use.

Be cautious that you should not use code category F17 with O99.32 as it is covered under the guidelines of tobacco use and not the drug use.

Codes under subcategory O99.33 Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium, should be used when a mother uses any type of tobacco product during the pregnancy or postpartum with a secondary code from category F17, Nicotine dependence, to identify the type of nicotine dependence.

From all the above key points and applying coding hierarchy, you can choose the codes for psychoactive substance use disorder with utmost accuracy.

Happy learning! Happy coding!


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