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Compliantly Capture the Elusive Diagnoses for Substance Abuse – Substance Abuse is not just a “psychiatric diagnosis” or a “social problem” as it can have a huge impact to patient health. Each provider has their own approach to determining when and how to assign a diagnosis of substance abuse. Some providers will not touch this family of diagnoses; the session will address the best strategies for this. Linking substance abuse to medical problems is key to showing medical necessity and severity of illness in many cases. This session will provide insight and tools to identify the clinical parameters driving the diagnoses for different types of substance abuse, queries and suggested education for providers across all specialties.

Learning Objectives/Agenda:

• Provide education to on the evolving terms used to describe the Disease of Addiction
• Introduce the scoring systems needed document and drive the diagnoses for Substance Use Disorders
• The session will take a deep dive into distinguishing between Substance Use versus Abuse versus Dependence
• ICD-10-CM is in the process of evolving to reflect the current clinical criteria
• Provide query options for identifying / distinguishing between use, abuse and dependance the type of substance abuse
• Provide guidance for identifying associated physical problems caused by substance use and linkage for diagnosis assignment

Why is this topic important?

According to the Centers for Disease Control and Prevention (CDC), 13% of Americans reported increasing or starting substance use as a way of coping with stress related to the COVID pandemic.
There is an 18% increase nationwide in opiate overdoses.
Substance Use Disorders got an overhaul as of January 1, 2022, in ICD-11

Who would benefit from this topic?

• All professional/provider coders who assign ICD 10 CM diagnoses in any setting
• All inpatient facility coders who assign ICD 10 CM diagnoses in any setting
• All Outpatient facility coders who assign ICD 10 CM diagnoses in any setting
• All coders providing services in any setting providing mental health or substance use treatment

What’s your background/expertise on this topic?

Nancy was a registered nurse for 46 years and worked for 2 years as a Director of Nursing in Psychiatric hospitals. She has 3.5 years working in of experience working in adult, adolescent and child psychiatry in a university setting. She has performed coding audits for multiple clients providing mental health and substance use services.