outpatient clinical stabilization unit

rchojnowski

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Does anyone have any feedback yet on the diagnosis coding for an outpatient clinical stabilization unit. Some of our patients are transitioning from our Inpatient substance abuse detox back into society via a housing unit where the live for a period attending therapy. We have opened this new type of facility to assist in addressing the growing opiate abuse crisis. Are you using Z71.41 as your principle diagnosis? Or just the abuse/dependence code? And what type of documentation do you have to code your diags from? Thank you for any information on your experiences with this type of unit.
 
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Assuming these patients are no longer dependent and abusing the substance... I would code for the substance dependency in remission and the counseling/surveillance
As you mentioned, a patient who had an opioid dependency; Z71.51 Drug abuse counseling and surveillance of drug abuser (but it has a "use additional code" direction), so I'd add F11.21 Opioid dependence, in remission.
Using Z71.41 Alcohol abuse counseling and surveillance of alcoholic, it also has the use add'l code direction, so you'd have to find an appropriate code F10.-; maybe F10.21 Alcohol dependence, in remission.

Obviously you need a reason for the encounter, which would be the Z71.- code, but those codes indicate you have to use add'l code to identify the drug and the status of use from the "F" sections listed, so you have to have a second code.
 
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