Wiki Coding polysubstance versus each individual substance, documentation

[trenam]

When auditing an encounter I see polysubstance (F19.10) documented. However, provider has reported out every single substance. Does the documentation need to state every dx for each substance to use each one individually or can the substance abuse code be used? Can someone point me in the right direction.

 

[xXxPARAGONxXx]

When auditing an encounter I see polysubstance (F19.10) documented. However, provider has reported out every single substance. Does the documentation need to state every dx for each substance to use each one individually or can the substance abuse code be used? Can someone point me in the right direction.

Who exactly coded polysubstance abuse (F19.10)? Was it the provider him/herself or a coder abstracting the provider's note?

 

[missaw3]

I think it depends on the provider and/or hospital you work for. The one I work for is okay combining the substances into the F19.10 code. I would ask for clarification on how they would prefer it was done for reporting purposes.