Q&A: Reporting unspecified drug use in ICD-10-CM

Q: When would you use the ICD-10-CM codes for opioid or marijuana use when no mental, behavioral, or other disorder is connected? I’m specifically thinking of codes F11.90 (opioid use, unspecified, uncomplicated) and F12.90 (cannabis use, unspecified, uncomplicated).

This lack of an applicable code for this usage seems strange. Some of the results of drug use are social and not directly documented by the physician as connected.

A: In essence, you would not report unspecified drug use. In fact, I wouldn't be surprised if these codes are eventually deleted. The ICD-10-CM Official Guidelines for Coding and Reporting state:

As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The 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.

Note that this guidance only applies to the substance use codes, not abuse or dependence. If there is a question of any associated disorder (perhaps addressed in a non-physician practitioner note), query the provider for the clinical significance and if it should be documented, as the physician is accountable for establishing the diagnosis.

Editor’s note: Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, coding regulatory specialist for HCPro in Middleton, Massachusetts answered this question.

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.