# Documenting the Use of CBD Oil



## slc112071 (Apr 30, 2019)

Could you please give me your opinions on the documentation of the use of CBD oil in a physician's office note in Texas, where the use of Marijuana is illegal?  Should the physician stay neutral and not mention it at all, or document that the patient uses it?


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## mitchellde (Apr 30, 2019)

CBD oil and cannabis are two very different things.  CBD oil can be purchased in any state and distributed thru the mail system,. it is not illegal, it has no THC.   It is a naturopathic remedy.  The oil with the THC in it,  available only where cannabis is legal, is not marketed as CBD oil.


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## rachaelwilleford (Apr 30, 2019)

mitchellde said:


> CBD oil and cannabis are two very different things.  CBD oil can be purchased in any state and distributed thru the mail system,. it is not illegal, it has no THC.   It is a naturopathic remedy.  The oil with the THC in it,  available only where cannabis is legal, is not marketed as CBD oil.



While it contains little or no THC, CBD oil is actually illegal in some states because hemp and hemp derived products is classified as marijuana.  Board of Pharmacy ruled CBD oil as an illegal substance in Louisiana, and there are some other states were the legality is refuted as well.  It's best to check state regulatory law in regards to this product.


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## mitchellde (May 1, 2019)

I understand what you are saying but CBD oil with THC is illegal in many states.. the is however CBD oil with no THC, and even in Missouri there are stores that sell CBD oil over the counter and it can be ordered over the internet and shipped anywhere.   The point being CBD oil is not cannabis/marijuana and therefore not coded as cannabis use.  It is a naturopathic remedy used by millions.  I would not give it second look, treat as you would any over the counter remedy.


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## lori mitchell (May 3, 2019)

Hi. I believe the original question was whether the physician should document the use. If the physician considers it potentially relevant to the patient's care, it would seem appropriate for the physician to document the use, regardless of whether it is legal or not in the given state. However, I would strongly encourage the physician to discuss this with his/her malpractice carrier and apply their guidance.


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## Pathos (May 3, 2019)

I have seen many medical records which includes the use of illegal substances (meth, cocaine, heroin), and last time I checked those drugs are still very much illegal. Since these substances will have some type of effect on the patient's overall health status, I would say the provider has an obligation to document the illegal drug abuse in the chart. Whether or not they should report this to law enforcement is a completely different discussion, however in terms of healthcare and proper/best practices documentation, the provider should always document anything that could have an effect on the medical management of their patient.


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## KellyLR (May 3, 2019)

*Responding to coder question concerning physician documentation of CBD oil use*

Hi,

I don't know what happened to the first post I posted but I will post again. CBD oil is derived from the marijuana plant. Doesn't matter if it it has THC in it or not when it comes to Texas. Marijuana plants and all products manufactured from it are technically illegal in this state. CBD manufacturers discreetly package their product and ship to the wholesalers in Texas and other states that still state marijuana is illegal. CBD is a cannabinoid of the marijuana plant. In Texas, this will be confiscated along with any other cannabis products when they enforce the law. The question was concerning if the provider should document the patient's use of CBD oil. *Yes, the provider can document patient use of this substance. I would advise the coder to check with the specific payer like Aetna to see what the payer guidelines have to say when reporting. * FYI, I currently code remotely for two hospital systems in TX. I also concur with Pathos and Lori's posts.


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## CodingKing (May 3, 2019)

There is no code for CBD oil use so why does it matter?


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## Pam Brooks (May 6, 2019)

KellyLR said:


> Hi,
> 
> I don't know what happened to the first post I posted but I will post again. CBD oil is derived from the marijuana plant. Doesn't matter if it it has THC in it or not when it comes to Texas. Marijuana plants and all products manufactured from it are technically illegal in this state. CBD manufacturers discreetly package their product and ship to the wholesalers in Texas and other states that still state marijuana is illegal. CBD is a cannabinoid of the marijuana plant. In Texas, this will be confiscated along with any other cannabis products when they enforce the law. The question was concerning if the provider should document the patient's use of CBD oil. *Yes, the provider can document patient use of this substance. I would advise the coder to check with the specific payer like Aetna to see what the payer guidelines have to say when reporting. * FYI, I currently code remotely for two hospital systems in TX. I also concur with Pathos and Lori's posts.




To answer your question, providers should document all PFSH as it relates to patient care, including the use of legal and illegal substances, over the counter medications, herbs, supplements, essential oils, devices, or any other agent or supply that may impact of affect medical care.

What we want to be careful of as professional coders is that we do not let our personal opinions with regards to use of any of these substances cloud our judgement or otherwise influence our education to our providers or even more importantly, our opinion of our patients.


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