How exciting! The day has finally come (and passed) wherein coding professionals could apply theory to practice. After years of education, training, and preparing for ICD-10 on October 1, 2015 coders were able to flip through crisp pages and navigate their way through the Alphabetic Index and Tabular Section of their new 2016 ICD-10-CM codebooks. Super Coders reported to duty, eager and ready to conquer clinical documentation battlegrounds. On a mission to capture diagnoses to the greatest level of specificity in a way never achieved before, aiding in improved coding and reporting, optimal patient care, timely and accurate reimbursement, research, and improved data quality.
Among the many new concepts introduced, unique codes for alcohol and drug use, abuse, and dependence were developed; therefore, a careful review of the documentation is required to ensure accurate reporting. In the midst of the continued excitement coders must not thrust full speed ahead without possessing an in-depth knowledge of the ICD-10-CM Official Guidelines for Coding and Reporting as it pertains to these conditions.
A psychoactive substance (e.g. tobacco, alcohol, amphetamines, cannabis, cocaine, and heroin) acts primarily on the central nervous system where it alters brain function, resulting in temporary changes in perception, mood, consciousness, and behavior. Mental disorders are secondary to brain disorders. The intent behind the creation of the codes was not to identify and label all patients as users, abusers, or those dependent upon psychoactive substances; but rather to identify the relationship between these substances and mental or behavioral disorders.
Let’s take a closer look!
Conundrum #1 – “In Remission”
Patients can successfully achieve remission (categories F10-F19 with -.21). In remission and personal history are classified the same for alcohol and drug dependence. Section I.C.5.b.1 of the Official Coding Guidelines for Coding and Reporting states: “Mental and behavioral disorders due to psychoactive substance use require the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation.”
Conundrum #2 – “Hierarchy”
A hierarchy was developed to prevent over-coding/reporting as well as to ensure only the highest level of severity is captured. Section I.C.5.b.2 of the Official Coding Guidelines for Coding and Reporting states: “When the provider documentation refers to the use, abuse, and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use.”
The final code assignment is based on the following hierarchy “Dependence” is principal to “Abuse”, which is principal to “Use”.
Conundrum #3 – “Coding from the Social History”
Psychoactive Substance Use is commonly documented in the patient’s social history. The standard rule of thumb has always been, if it’s not documented you can’t code it, but as we all know there are exceptions to the rule, caveats, in the cosmic coding circle.
Section I.C.5.b.3 of the Official Coding Guidelines for Coding and Reporting states: “As with all other diagnoses, the codes for psychoactive substance use should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis. The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.”
Conundrum #4 – “Reportable Diagnoses”
All documented diagnoses are not necessarily reportable diagnoses. A reportable diagnosis is one that affects patient care in terms of requiring:
- clinical evaluation; or
- therapeutic evaluation; or
- diagnostic procedures; or
- extended length of hospital stay; or
- increased nursing care and/or monitoring
Common coding errors include capturing psychoactive substance use directly from the patient’s documented social history without a documented associated mental or behavioral disorder. In the Alphabetic Index to Diseases and Injuries under the main term, Use, use of psychoactive substances leads to a code in categories F10-F19 with the exception of tobacco; therefore, careful measurements must be taken to ensure the coder is not interpreting clinical documentation. Once reported, these conditions are inclusive of a patient’s permanent, legal medical record and may have negative implications with regards to continued insurance eligibility, state licensing, and employment.
When in doubt, query, to avoid your spaceship from being sunk!
About the Author
Tanai S. Nelson is the Senior Director, Coding and HIM Operations at Eclat Health Solutions (Eclat). Tanai is an AHIMA- approved ICD-10-CM/PCS Trainer and Ambassador, also accredited in RHIA, CCS, CCS-P.
She also held various coding, reimbursement, and education roles within multiple healthcare and nontraditional settings including physician practice, hospital outpatient care, hospital acute care, academia, professional association, health information systems (HIS) vendor, as well as a health insurance company during her 17-year career as an accomplished HIM professional.
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