The double entendre in the title is pure dumb luck, and I left it there for fun. Some days we might all prefer imbibing something that messes with our brain chemistry to thinking about ICD-10. It would be nice to just wake up to a steaming mug of coffee and a more rational world when the crazy ICD-10 politics are over. That is not the world we live in at the moment, however, and there is work to be done in the meantime. So let’s look at how substance abuse codes are classified in ICD-10.
Substance use, abuse and dependence codes in ICD-10 are both more precise and more practical. For 30 years you have had to put up with ICD-9 substance abuse codes that ask about the patient’s pattern of use — episodic, continuous or unspecified — and ICD-9 doesn’t define these subjective terms. So you did what anyone in your situation would do, you didn’t use these words in your documentation, so the pattern of use that got coded was the unspecified code, as in
304.00 Opioid type dependence, unspecified.
ICD-10 has jettisoned pattern of use as an axis of classification, and replaced it with some useful, more efficient stuff. Documentation requirements for specific ICD-10 substance abuse codes can be characterized by this question:
Is there a current acute manifestation, or is there a chronic disorder resulting from longer-term use of the substance?
If the answer to that question is no, then the code you will want to use contains the word uncomplicated in the description, and the key differentiating words to document are use, abuse or dependence. The clinical criteria for characterizing a patient’s substance use as abuse vs. dependence are well established, so they should not give you any difficulty. The codes below can be used without any documentation beyond the type of substance and the word abuse or dependence as appropriate. Unspecified use is the default code when neither abuse nor dependence are documented.
F11.90 Opioid use, unspecified, uncomplicated
F11.10 Opioid abuse, uncomplicated
F11.20 Opioid dependence, uncomplicated
In ICD-9, acute manifestations associated with abuse or dependence such as delirium typically require two separate codes. In ICD-10 these conditions can be captured with a single specific code. Below are a couple of examples for coding opioid dependence with a current acute manifestation.
F11.221 Opioid dependence with intoxication delirium
292.81 Drug-induced delirium
304.00 Opioid type dependence, unspecified
F11.23 Opioid dependence with withdrawal
292.0 Drug withdrawal
304.00 Opioid type dependence, unspecified
The same is true for coding ongoing disorders resulting from longer-term use of a substance. This amount of detail requires two codes in ICD-9 and only one in ICD-10. “Insomnia due to cocaine dependence” can be coded in ICD-10 as below.
F14.282 Cocaine dependence with cocaine-induced sleep disorder
292.85 Drug induced sleep disorders
304.20 Cocaine dependence, unspecified
And finally, the codes for tobacco users reflect what is in fact the case — your patients do not have a “tobacco use disorder,” they are nicotine dependent. ICD-10 allows you to distinguish between the major significant types of tobacco — cigarettes, chewing tobacco, and others such as cigars and pipes — so that the long-term consequences of the respective type can be more easily tracked.
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.290 Nicotine dependence, other tobacco product, uncomplicated
305.1 Tobacco use disorder
Unless something comes along and interrupts the plan, the rest of this blog series will focus on ICD-10 coding by physician specialty, such as cardiology, orthopedics, oncology and so forth. The theme of these blogs so far has been that much too much has been made of the differences between code sets and the difficulty those differences will create for physicians. Both claims are overblown — surprise — for political reasons. So my goal here is a modest one: to get some actual information about coding and documenting for ICD-10 in front of your eyes and let you make your own decision. Since we are scientists at heart, why accept unfounded claims?
Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC. She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.