Code to the “Highest Severity” for Drug Use, Abuse, and Dependence

Code to the “Highest Severity” for Drug Use, Abuse, and Dependence

When reporting a patient’s drug use, abuse, or dependence, ICD-10-CM guideline 5.C.2 states:

Psychoactive Substance Use, Abuse And Dependence 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.

In other words: Code to the highest severity.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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