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.
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