Primary Care Coding Alert

Question: A patient presents with depression and feelings of nervousness. During the social history, the patient admits that he drinks excessively and uses marijuana regularly. The FP counsels the patient for depression, encourages the patient to reduce his substance intake and refers him to a psychiatrist. The doctor uses the diagnosis codes for depression (311) and nervousness (799.2) but also wants to report substance abuse. Should I include these codes?

Massachusetts Subscriber

Answer: A diagnosis of substance abuse can have negative consequences for a patient. Although claims processing has a certain amount of privacy, it is not as private as the patient's medical record. Documenting that the patient admits to abusing alcohol and marijuana is not as harmful as diagnosing that patient with substance abuse and recording it as part of the patient's payment history. If you diagnose a patient with substance abuse, it should be necessary to the coding of that visit.

Whether you use the substance abuse codes depends on several factors. The depression and nervousness diagnosis codes were used because treatment for those problems required medical decision-making the family practitioner (FP) referred the patient to a psychiatrist. But the FP only "encouraged" the patient to cut down on substance abuse. Ask your physician if telling the patient to cut down counts as counseling. If so, you can use the substance abuse codes. In this case, report 305.21 (Cannabis abuse, continuous) and 305.01 (Alcohol abuse, continuous). If the physician did not counsel the patient on substance abuse issues, use only the depression and nervousness codes. The FP should also have documentation of a blood, urine or hair test proving substance abuse to report these diagnosis codes.

You should also consider the link between the depression and substance abuse. If your physician determines that one is contributing to the other, include the substance abuse codes. If, however, the physician says the two problems are not related, you may not want to use them.

Answers to You Be the Coder and Reader Questions provided by Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians; Brett Stanaland, MD, allergist immunologist at Naples Community Hospital in Naples, Fla., and assistant clinical professor of medicine at the University of South Florida; and Judy Richardson, RN, MSA, CCS-P, at Hill & Associates, a coding and compliance consulting company in Wilmington, N.C.