Wiki Substance Use Disorder

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mreed63

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Hi, there. Looking for some clarification on the General Coding Guideline below:
I.C.5.b.3
3) Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.

My question is, does an associated physical, mental, or behavioral disorder have be to be documented by the provider when a specific disorder [for example, cocaine abuse, uncomplicated or alcohol abuse, uncomplicated] is documented and there is not any other physical, mental or behavioral disorder present. In other words, if I'm capturing F1410 Cocaine abuse, uncomplicated, or F1020 Alcohol dependence, uncomplicated, do I need to see an associated physical, mental or behavioral disorder association relationship documented, in order to capture those codes?

Appreciate any clarification!
 
So I've been out of mental health for a while, but here is what I'm thinking. It's goes along the lines with getting certain things removed from the DSM as a disorder. If it's not bothering you or someone else, it's not a disorder. For instance, someone who dresses up in the opposite gender's clothing is no longer a disorder, as long as it is not causing a problem.

So cocaine abuse is not a problem if it's not bothering you or someone else. If they are being treated for it, then that makes it a problem. Does that make sense? If they are being seen because they broke their foot, and they just happen to also do cocaine, unless they broke their foot because they were high on cocaine, you don't code the cocaine abuse.
 
That's basically correct. What the section III guidance says is that a reportable diagnosis is one that the provider has documented as affecting patient care. Which I've interpreted to mean is that you would not use a code from these ranges simply because the patient has reported that they have used a drug or that they drink alcohol socially. The provider needs to specifically state that this is a problem that exists and affects treatment in some way at the particular encounter that is being coded.
 
Wowsers...great explanations! It makes more sense to me now and am far more confident in offering clarification to my team.
Thank you a lot so much!
 
mreed63 said:
Hi, there. Looking for some clarification on the General Coding Guideline below:
I.C.5.b.3
3) Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.

My question is, does an associated physical, mental, or behavioral disorder have be to be documented by the provider when a specific disorder [for example, cocaine abuse, uncomplicated or alcohol abuse, uncomplicated] is documented and there is not any other physical, mental or behavioral disorder present. In other words, if I'm capturing F1410 Cocaine abuse, uncomplicated, or F1020 Alcohol dependence, uncomplicated, do I need to see an associated physical, mental or behavioral disorder association relationship documented, in order to capture those codes?

Appreciate any clarification!
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Hello,
I'm looking for similar clarification. I feel like I understand the guideline, but am having difficulty in real world application of it. If providers are using "opioid use disorder" or "OUD" and using F11.90 what should I do? Do I query the provider asking for more specificity - i.e. is the diagnosis mild, moderate, severe (so that I can use F11.10 or F11.20? My understanding is that F11.9 "opioid use unspecified" does not equal "disorder." Is there any more specific guidance? For some reason, I cannot get my head around this.
Thanks!
 
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