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Documentation for Drug-related Disorders with ICD-10 Medical CodesWhen it comes to psychiatry medical billing, addiction to any drugs can be documented using ICD-10 codes. While these drugs are necessary to treat psychiatric conditions, the sad truth is that they are often abused leading to adverse events including death. Non-medical use and abuse of prescription drugs is a growing health problem in the United States. Misuse of prescription and opioid drugs has been a topic of concern for a long time. Overdoses on prescription drugs can lead to death. According to the California Department of Public Health, there are more unintentional deaths due to prescription medication overdoses there than deaths occurring due to traffic accidents. With the severity of the problem of prescription opioid and heroin abuse, President Obama has also assigned an additional $1.1 billion in the 2017 budget to fight the issue in the U.S.

Let us consider the clinical documentation of substance abuse. Perfect documentation is critical not only for correct reimbursement, but also to understand the seriousness of the illness. ICD-10-CM includes codes to specifically report the “use” of alcohol and drugs. Codes that can be relevant for drug use are –

  • F11.1- Opioid abuse
  • F11.2- Opioid dependence
  • F11.9- Opioid use, unspecified
  • F12.1- Cannabis abuse
  • F12.2- Cannabis dependence
  • F12.9- Cannabis use, unspecified
  • F13.1- Sedative, hypnotic or anxiolytic-related abuse
  • F13.2- Sedative, hypnotic or anxiolytic-related dependence
  • F13.9- Sedative, hypnotic or anxiolytic-related use, unspecified
  • F14.1- Cocaine abuse
  • F14.2- Cocaine dependence
  • F14.9- Cocaine use, unspecified

However, these codes do not provide information regarding the drug, the acuity of the condition, and any associated conditions that might be present. There are a few such descriptive codes that remain applicable only to alcohol (Example, F10.121, alcohol abuse with intoxication delirium and F10.14, alcohol abuse with alcohol-induced mood disorder)

It is crucial that the clinical documentation clearly specifies the severity of illness as well. The documentation should provide information regarding any associated condition such as intoxication, delirium, perceptual disturbance, sexual dysfunction, psychotic disorder, delusions, hallucinations, or mood disorder.

Clinicians can specify the type of drug use as use, abuse, and dependence. As per ICD-10-CM guidelines,

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

ICD-10 codes are more organized, logical and efficient providing many more combination codes, thus making the medical coding process easier.