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 a contributing editor at AAPC. He has been covering 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.
John Verhovshek

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About Has 605 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering 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.

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

  1. santosh guptha says:

    Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).
    Dr Santosh Guptha, medical coder at https://www.medesunglobal.com

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