By Heather Greene, MBA, RHIA, CPC, CPMA

ICD-10-CM has given us a structurally sound and evidence-based system in order to report substance use disorders. With a little bit of perusing and research, a coder will find the reporting of these conditions to be logical, consistent and easily documented.

In order to report substance use appropriately in ICD-10-CM, the documentation requirements have changed. The language requirements differ slightly from DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). DSM-5 has combined this condition under Substance Use Disorder, which is then delineated as mild, moderate or severe. This approach is in line more with ICD-10 and less in line with the United States modified ICD-10-CM. In order to report this condition in ICD-10, the practitioner will need to clarify these terms using ICD-10-CM vocabulary.

ICD-10-CM reporting does require documentation that clarifies the level of severity of the substance use by defining use, abuse or dependence. It also requires the documentation of any intoxication as well as any acute manifestations or complications.

Differing from ICD-9, ICD-10 no longer requires the documentation of the vague terms, episodic, continuous or unspecified.

It is important to note the exclusion of withdrawal under acute intoxication and acute intoxication under withdrawal. For example, under ICD-10-CM code F11.22-, Opioid dependence with intoxication, there is an Excludes 1 note for ICD-10-CM code F11.23, Opioid dependence with withdrawal. And when reviewing ICD-10-CM code F11.23, Opioid dependence with withdrawal, there is an Excludes 1 note for F11.22-, Opioid dependence with intoxication. We know it is possible to have both in one encounter so the question of reporting becomes prominent. The ICD-10 classification of Mental and Behavioral Disorders* clarifies the nomenclature definitions resulting in a natural hierarchy of reporting. In reading the definitions listed below, it becomes clear that substance dependence with acute intoxication should only be reported when there is not a complication or acute manifestation.
In ICD-10-CM the type of nicotine dependence should be reported. It is important for physicians to move away from using "tobacco abuse" and specify the type of nicotine the patient uses, for example, smoking cigarettes or a pipe or chewing tobacco.

Documentation Requirements:

• Specify substance
  - Nicotine type
  - Extensive history of substance use disorder
  - Blood alcohol level (if known)
• Acute intoxication:
  - With or without complication
• Is there a current acute manifestation, or is there a chronic disorder resulting from a longer-term use of the substance?
  - No - Use the code that contains the word uncomplicated
  - Yes - Move to the codes that better describe the problem
• Use, abuse or dependence:
  - Use established clinical criteria to differentiate between use, abuse or dependence.
  - Best practice is to state the appropriate key word of use, abuse or dependence.
• ICD-10 codes for substance use and acute manifestations are combination codes:
  - Document the manifestation or complication for example:
  + Withdrawal
  + Insomnia due to substance dependence
  + Perceptual disturbance
  + Dementia
  + Intoxication

Definitions:*

Acute Intoxication
A transient condition following the administration of alcohol or other psychoactive substance, resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.
Acute intoxication should be a main diagnosis only in cases where intoxication occurs without more persistent alcohol- or drug-related problems being concomitantly present.

Harmful Use (Abuse in ICD-10-CM)
Harmful use is defined as a pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Dependence Syndrome
Dependence syndrome is defined as a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviors that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals.

Withdrawal State
Withdrawal state is defined as a group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a substance after repeated, and usually prolonged and/or high dose, use of that substance. Onset and course of the withdrawal state are time-limited and are related to the type of substance and the dose being used immediately before abstinence. The withdrawal state may be complicated by convulsions.

Psychotic Disorder
Psychotic disorder is defined as a cluster of psychotic phenomena that occurs during or immediately after psychoactive substance use and is characterized by vivid hallucinations (typically auditory, but often in more than one sensory modality), misidentifications, delusions and/or ideas of reference (often of a paranoid or persecutory nature), psychomotor disturbances (excitement or stupor), and an abnormal affect, which may range from intense fear to ecstasy. The sensorium is usually clear but some degree of clouding of consciousness, though not severe confusion may be present. The disorder typically resolves at least partially within one month and fully within six months.

Amnesic Syndrome
Amnesic syndrome is defined as a syndrome associated with chronic prominent impairment of recent memory; remote memory is sometimes impaired, while immediate recall is preserved. Disturbances of time sense and ordering of events are usually evident, as are difficulties in learning new material. Confabulation may be marked but is not invariably present. Other cognitive functions are usually relatively well preserved and amnesic defects are out of proportion to other disturbances.

* The ICD-10 Classification of Mental and Behavioral Disorders has not been translated to ICD-10-CM. However, its definitions and reasoning enable us to understand the overall structure of chapter five in ICD-10-CM and how to report conditions.

Heather Greene is the vice president of compliance services with Nashville-based Kraft Healthcare Consulting, LLC, an affiliate of KraftCPAs PLLC. With more than 20 years of experience in the healthcare industry, Heather uses her expertise while consulting on billing, coding and operations matters and performing coding and documentation reviews. She also provides expert reports in litigation matters, conducts educational sessions for physicians and HIM personnel, and speaks on a variety of healthcare topics both locally and nationally.

Heather received a bachelor's degree in health information management from Eastern Kentucky University and an MBA from Midway College. Additionally, she holds the following certifications: Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC) and Certified Professional Medical Auditor (CPMA). She continues to strive for excellence and increased knowledge by participating in the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC). Heather is also an AHIMA approved ICD-10-CM/PCS trainer, an AHIMA ambassador and is AAPC ICD-10-CM proficient.

heather@krafthealthcare.com
krafthealthcare.com