Psychiatry Coding & Reimbursement Alert

Question: In the previous edition of the Psychiatry Coding Alert (vol.5, no.7), there was a reader question on reporting substance related psychosis. When I was going through the various ICD-10 codes for substance and alcohol abuse, I saw that there are codes for “use,” “dependence” and “abuse.” How should I identify which of the codes to use if our clinician has not specifically used these terms in the patient notes?

Pennsylvania Subscriber

Answer: As you have observed, the alcohol and substance abuse ICD-10 codes are all categorized on the extent of use of the said substance. So, you will have three categories for each of these code sets under “use,” “dependence” and “abuse.”

You will have to use the “dependence” set of codes if the person has an addiction to the particular substance that he or she is using and stopping the usage of the said substance will result in withdrawal symptoms. You have to report the diagnosis with the “abuse” set of codes if the person’s addiction is not under control with the person using more amounts of the substance than previously used and having life-threatening situations or highly dangerous effects.

On the other hand, you will use the “use, unspecified” set of codes when your clinician has not mentioned the extent of usage of the substance.

So, for instance, if the patient is known to be addicted to alcohol but has not been abusing it, you can report the diagnosis using the F10.2- (Alcohol dependence) set of codes. If the patient is taking very high amounts of alcohol and is always under the influence, you report this diagnosis with the F10.1- (Alcohol abuse) set of codes.

And, as in your case, if the clinician does not specify the level of use, you can use the F10.9- (Alcohol use, unspecified) set of codes.

Note: Sometimes, provider documentation may refer to use, abuse, and dependence of the same substance (e.g., alcohol, opioid, cannabis, etc.). In this situation, per ICD-10-CM guidelines, only one code should be assigned to identify the pattern of use based on the following hierarchy:

• If both use and abuse are documented, assign only the code for abuse.
• If both abuse and dependence are documented, assign only the code for dependence.
• If use, abuse and dependence are all documented, assign only the code for dependence. 
• If both use and dependence are documented, assign only the code for dependence.