Documentation and Coding: Substance Use Disorders

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.  Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.”

Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance use disorder is based on diagnostic criteria for the pattern of behaviors. Treating substance use disorder is challenging and varies depending on the substance and circumstances.

Documentation & Coding Tips 

Documentation needs to be clear and detailed using the following terms to allow accurate ICD-10 code selection.

Specificity:

• Substance name
  
• Type of disorder: use, abuse, dependence, withdrawal
  
• Severity: mild, moderate, or severe
  
• Status: current, in remission (partial or full)
  

Complications and/or associated conditions: Document & code the relationship between the substance disorder and any associated physical, mental, or behavioral disorder, such as...   

• Intoxication, withdrawal, delirium, perceptual disturbance,
  
• Mood, anxiety, sleep, sexual dysfunction, depressive, psychotic disorders,
  
• Psychoactive substance withdrawal can occur in individuals who do not have a diagnosis of dependence but who use the substance regularly (i.e., use or abuse) and then reduce or cease the use.
  

Treatment:

• Document treatment (medication, psychotherapy, or a combination of both) and current response to treatment.
  
• Document any treatment refusals, or non-compliance.
  

Other:

• If the provider documents use, abuse, and dependence of the same substance use the following hierarchy when coding.