Wiki Substance abuse

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nikkimalahan

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If provider documents substance abuse in full remission, how should i code it? there is no remission code for abuse. would I just not code it because it is inactive?
 
You will need clarification from the provider if you look,under personal history, drug, abuse, it says see drug, dependence by type then remission.
 
Thanks

the confusion is that its not dependence, its stated abuse. To make it more confusing DSM 5 doesn't use the terms abuse or dependence. So it is documented as mild which crosses over to abuse. To code it as dependent would be incorrect.
 
Are you sure the provider's notes are worded properly?

a person that has alcohol use disorder- if they are no longer abusing it, they are then classified as "dependent" on alcohol.
if none of the criteria for alcohol use disorder has been met in a 12 month or longer time period, then the patient is in remission.
The proper wording would be alcohol dependent in sustained remission, F11.22.

I understand your dilemma, Im faced with it all the time, when a clinician has not been properly trained and the notes are inconsistent.

However, someone who has alcohol abuse, can not be in remission.
Once the "abuse" is over, and then they become "dependent" (F11.10/20) thats when they can eventually be in sustained remission. F11.22

hope this helps.
 
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