Wiki Drug USE coding

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HeidiLeeCrawford

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Drug USE coding [when not listed as Dependence or Abuse]

Hello,

I am fairly new to coding and I am seeing alot of my Doctors stating Drug use in their reports.(usually through the patient saying they use it or the presence of the drug in blood/urine screenings and they are not a part of their prescribed medicines) They do not specify if it is abuse or dependence. Should I just code the presence of the drug in blood/urine or should I code dependence or abuse? Or is there a more appropriate code to use? I am seeing many of these now especially with the opioid crisis. Any advice would help. Thank you!
 
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I am also new to coding. However, this seems like a situation which should be clarified by the providers. If you code for multiple providers in a practice, they may want to agree upon terminology/wording for documenting drug use/abuse/dependence for all patients seen by the practice.
 
unless the provider indicates the patient uses an illegal substance then you would not code it all. If the provider states the patient does use a drug then you code just drug use not abuse or dependence. IF cannabis is legal recreational in your area then you need to be care regarding cannabis use just because it is mentioned. there are numerous patients that use cannabis and it is not a problem for them or the provider. The provider must document if it is a use beyond what is recreational.
 
Drug Use coding, not dependence or abuse

mitchellde said:
unless the provider indicates the patient uses an illegal substance then you would not code it all. If the provider states the patient does use a drug then you code just drug use not abuse or dependence. IF cannabis is legal recreational in your area then you need to be care regarding cannabis use just because it is mentioned. there are numerous patients that use cannabis and it is not a problem for them or the provider. The provider must document if it is a use beyond what is recreational.
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Most of time the providers usually just state something along the lines of "Urine test positive for amphetamines/opioids/cannabis/etc." and the patient isn't using any of these based on their provided prescription list. But I am confused on the drug use codes you state above to use. I haven't really found a "use" code I can use for these. Am I just missing them? Sorry I am just kind of confused here. (And cannabis is not legal here.)
 
You cannot code drug use based on a lab result being positive for a drug.. you must have the provider document that the patient uses the drug in a non compliant or harmful manner. F11.90 is opioid use, F15.90 for stimulant use for the amphetamines, F12.90 for cannabis use.. the drug codes are all in the F10-F19 categories and most have a use, uncomplicated selection choice.
 
Drug Use coding, not dependence or abuse

mitchellde said:
You cannot code drug use based on a lab result being positive for a drug.. you must have the provider document that the patient uses the drug in a non compliant or harmful manner. F11.90 is opioid use, F15.90 for stimulant use for the amphetamines, F12.90 for cannabis use.. the drug codes are all in the F10-F19 categories and most have a use, uncomplicated selection choice.
Click to expand...

Oh! That makes more sense. Thank you! i really appreciate the help
 
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