Neurosurgery Coding Alert

Question: One of our patients is a former opioid addict, and I am not sure what ICD-10 code I should use to document this. Should I use F11.21 to indicate the patient is in remission, or should I use a history code such as Z86.59? Are there any ICD-10 guidelines for this? Or is there a medical definition that I can apply to determine code choice?

AAPC Forum Participant

Answer: There are no specific ICD-10 guidelines governing when to use remission or personal/family history codes, and there are no formal medical definitions you can apply. And while it might make sense to apply a history code based on whether your provider or an outside provider is no longer providing treatment for the condition, and a remission code if the patient is still receiving some form or treatment even though they are no longer abusing the drug, the reality is that you cannot assign a code this way.

Simply put, code choice in this situation is entirely based on provider documentation. As ICD-10 guideline C.5.b.1 states, “Selection of codes for ‘in remission’ for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.11, -.21) requires the provider’s clinical judgment. The appropriate codes for ‘in remission’ are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.”

In other words, unless you provider has documented whether the condition is in remission or is no longer a factor in the patient’s treatment plan, you cannot assign either F11.21 (Opioid dependence, in remission) or Z86.59 (Personal history of other mental and behavioral disorders).