Wiki Substance Dependence Code Capture

[mreed63]

Hi, there. This is a 2-part question for the Behavioral Health experts out there! Some of our providers are coding dependence for LTU of a drug (ex. opioid, anxiolytic, sedative) taken as prescribed, without any complications (side effects). My understanding is that is incorrect. DSM-5 criteria must be met to even consider dependence, and then the conversation between provider and patient must be documented to support the dependence capture. Secondly, how often does that conversation have to happen and be documented, when coding dependence - each time the code is captured or is there a defined cadence?

As always, appreciate your help!

 

[OpenClaims]

So, I know that you cannot code dependence and long term use of coincide one another. From my experience with BH coding, we've coded the long term use of (whatever medication) unless there were side effects, complications, or the like involved with the specific drug.

 

[TThivierge]

Hi MReed63
Dependence mental health for substance abuse means the patient is using and must be in the providers notations. If a pt. is on medications for a certain condition, provider should add the dx code/disease. Each time pt. is seen provider should discuss it and put in notes. If pt. stops SA behavior then it is like a remission period (ie F10.11) there are specific dx codes for this too. Also add the dx R41- R46 if describe behavior in documentation as 2nd dx code for applicable mental health actions/behavior. Also ensure if use terms substance abuse, provider should define it as pills, alcohol, opioid, cannabis, heroin. FYI.......sustained remission is more than a year and retained remission is less than 3 months. And sometimes I have to use the crap dx code F99 or F06 for mental disorders from poor notations. Also if the pt. has past history of sub abuse they need too but dates or year it happened if in the past. Past history and remission depends on wording by provider.
Well I hope this data helped you.
Lady T