Coding Opioid Use Disorder

Coding Opioid Use Disorder

When coding opioid use disorder, you’ll need to know the sequencing rules to select an appropriate ICD-10-CM code.
Opioid abuse, addiction, and overdoses are a serious public health problem. According to the National Institute on Drug Abuse, more than 115 people in the United States die after overdosing on opioids, every day. The Centers for Disease Control and Prevention estimates that the “economic burden” of prescription opioid misuse (including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement) in the United States equals $78.5 billion a year.
Opioid use, opioid abuse, and opioid dependence are grouped together as opioid use disorder. Per the Diagnostic and Statistical Manual of Mental Disorders (DSM–5):

The diagnosis of Opioid Use Disorder can be applied to someone who has a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Taking more opioid drugs than intended.
  • Wanting or trying to control opioid drug use without success.
  • Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs.
  • Cravings opioids.
  • Failing to carry out important roles at home, work or school because of opioid use.
  • Continuing to use opioids, despite use of the drug causing relationship or social problems.
  • Giving up or reducing other activities because of opioid use.
  • Using opioids even when it is physically unsafe.
  • Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway
  • Tolerance for opioids.
  • Withdrawal symptoms when opioids are not taken.

In ICD-10-CM, opioid use, abuse, and dependence are coded to category F11. Codes are chosen according to whether the patient is using, abusing, or is dependent on opioids, as well as any associated complications. Different subcategories have different associated complications; therefore, it is important to review each subcategory to ensure proper code assignment.

Coding Opioid Use: Which Code Takes Precedence?

Chapter 5 of the ICD-10-CM Official Guidelines for Coding and Reporting tells us:

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.

Because provider documentation is not always detailed enough to support proper code assignment, a query may be needed when coding opioid use disorders, to attain any missing pertinent information. To accurately track these injuries and to collect meaningful data leading to increased and efficient opioid management, proper provider documentation is key. Providers should be educated not to define “use” and “abuse” interchangeably, and not to document “use” or “abuse” when a patient is truly dependent on a drug.

John Verhovshek
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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.

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