Q&A: Determining the ICD-10-CM hierarchy for substance use, abuse, and dependence
Q: How would you code documentation where the provider states the patient is in remission for alcohol abuse and alcohol dependence?
A: Based on the hierarchy of use, abuse, and dependence per coding guidelines, dependence ranks highest in severity. This hierarchy is included in the ICD-10-CM guidelines for Chapter 5 (Mental, Behavioral and Neurodevelopmental Disorders), section b.2:
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 of use 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 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
When a patient presents with both abuse and dependence, dependence would be coded as it is the more severe condition. If a patient presents with abuse in remission and dependence in remission, code for the dependence in remission. If you are unsure, query the provider, as these are particularly sensitive codes. But according to the hierarchy for use, abuse, and dependence, the more severe condition would win in that scenario.
Editor’s Note: Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, a regulatory specialist for HCPro, an H3.Group division of Simplify Compliance LLC in Middleton, Massachusetts, answered this question during the HCPro webinar, “JustCoding’s 2018 ICD-10-CM Code Updates.” This answer was provided based on limited information. Be sure to review all documentation specific to your individual scenario before determining appropriate action.
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