Wiki Substance Related disorder

[snwhite0730]

Hello Coders,

I need an opinion on how to code this diagnosis. We are an IP Mental health hospital. We have a provider who sees a large majority of patients with substance use disorders. He has a tendency to use the diagnosis of 'Unspecified Substance Related disorder'. I have queried him in the past asking if the patient has a use/abuse/dependency and he tells me that the patient was not admitted long enough for him to state definitely what the level of usage is. I have been coding this as F15.988 or F15.959 (when he says the patient has meth induced psychosis). Does this seem like the best option? I have tried to educate the providers on documentation and requirements for abuse/dependency to really no avail as they still use unspecified or 'related disorder'.

 

[TThivierge]

Hello SN White
Why are you not using dx F11.259 is more detailed since it is opioid (aka as Meth)? Per the ICD10 dx manual Meth is a type of opioid. Unspecified sub abuse defines many kinds of specific drug abuse but providers need to be specific. The drug details or specifics are listed in the ICD10 manual or the Encoder.
Lady T

 

[snwhite0730]

The provider is not documenting dependency; F11.259 is Stimulant Dependency. The same as F11.159 is Abuse. All the doctor is stating is Stimulate Related Disorder. He doesn't say mild, moderate or severe. He doesn't document abuse, dependency or unspecified. There isn't a code for Meth Related Disorder. It's the use of 'Related' disorder that is getting me.