Wiki Drug use

[arkassabaum]

If a pt tells the provider he or she has recently used illegal drugs, such as heroin, marijuana, cocaine, etc.. Are we allowed to use the appropriate code (305 series) on the patients visit even though it may not be the reason they are there or even related to the visit? There was some debate in my office. I firmly believe in putting those codes on the visit (as secondary of course) because 1) it was mentioned in the document 2)if there is a problem in the future with drug use, we have history of when the code was first used and when it was officially documented that the pt admitted to use.

I tried looking in the icd 10 guidelines to see if it gave me a specific answer, i did find in icd 9 it states "includes cases where a person, for whom no other dx is possible, has come under medical care because of the maladaptive effect of a drug on which he is no dependent and that he has taken on his own initiative to the detriment of his health or social functioning."

to me that sounds like if they are there for it i can code it. But does that mean if they come in for a headache or sore throat and mention it to their provider that they smoke marijuana i cant code it at all?

Also additional question, are the providers/clinics legally responsible for reporting any drug use? or is that against hippa?