Coding spotlight: Substance use disorders and smoking
Substance use disorders can affect a person’s brain and in turn their behavior. Substance use can start with the experimental use of a drug in a social situation or exposure to prescribed medications. Eventually it can lead to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug- use disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article will provide you with the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.
Drug and substance addiction in the U.S.
The U.S. Department of Health and Human Services declared a public health emergency in 2017 due to an unprecedented opioid epidemic. Drug overdose deaths and opioid-involved deaths continue to increase in the U.S.1
Smoking is the leading preventable cause of death in the United States. According to the Centers for Disease Control (CDC), 15.5 % of all adults (37.8 million people) were current cigarette smokers in 2016.2
Health risks of drug use and smoking
Drugs can have significant and damaging short-term and long-term effects, including psychotic behavior, seizures or death due to overdose. Dependence on drugs can create a number of dangerous and damaging complications, such as accidents, suicide, family/work/school problems and legal issues.
Smoking diminishes overall health and is a known cause of multiple cancers, heart disease, stroke, complications of pregnancy, chronic obstructive pulmonary disease (COPD) and many other diseases. There are also health dangers of involuntary exposure to (second-hand) tobacco smoke. Smoking increases risks for preterm delivery.3
Diagnosis and treatment
Diagnosing substance use disorders requires a thorough evaluation and includes an assessment by a psychiatrist or a psychologist or an independently licensed behavioral health practitioner that has met the state requirements to render a diagnosis. Blood, urine or other lab tests are used to assess drug use.
People with behavioral disorders are more likely to experience a substance use disorder and people with a substance use disorder are more likely to have behavioral health issues when compared to the general population. According to the National Survey of Substance Abuse Treatment Services, about 45% of Americans seeking treatment of substance use/abuse have also been diagnosed with behavioral health problems.4
When diagnosing a substance use disorder, most mental health professionals use criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
Treatment depends on the type of substance used and any related medical or behavioral health disorders that the patient may have. Some treatment options include:
- Chemical dependence treatment programs
- Behavioral therapy
- Self-help groups
There are a lot of treatments to support tobacco cessation, including behavioral therapies and FDA-approved medications. Some treatment options to help ensure tobacco cessation include:
- Nicotine replacement therapy (NRT), as well as bupropion and varenicline
- Combination of behavioral treatment and cessation medications
- Mobile devices and social media help to boost tobacco cessation
- Tobacco cessations are not recommended for adolescents due to lacking high-quality studies
- Behavioral counseling can be provided either in person or by telephone and a variety of approaches are available such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), telephone support lines, text messaging, web-based services and social media.5
HEDIS® quality measures
Initiation and Engagement of Alcohol and Other Drug Abuse Dependence Treatment (IET) is a measure that assesses the percentage of plan members’ ages 13 years and older with the new episode of alcohol or other drug (AOD) abuse or dependence who received the following: initiation of AOD and engagement of AOD.
Initiation of treatment is the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
Engagement of treatment is the percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days after the initiation visit.6 This measure now includes medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. This measure also adds telehealth to treatment options.
Use of Opioids at High Dosage (UOD) is a first year quality measure that assesses the number of members 18 years and older per 1,000 beneficiaries receiving prescription opioids for ≥ 15 days during the measurement year at a high dosage (average morphine equivalent dose > 120 mg).7
Use of Opioids from Multiple Providers (UOP) is a first year quality measure that assesses the number of members 18 years and older per 1,000 receiving a prescription for opioids for ≥ 15 days during the measurement year who received opioids from multiple providers. Three rates are reported:
- Multiple prescribers – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers during the measurement year
- Multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
- Multiple prescribers and multiple pharmacies – the rate per 1,000 members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.7
Unhealthy Alcohol Use Screening and Follow-Up (ASF) is a measure that assess the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care.
- Unhealthy alcohol use screening – the percentage of members who had a systematic screening for unhealthy alcohol use
- Counseling or other follow-up – the percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening.
The intent of the measure: alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S.7
Medical Assistance with Smoking and Tobacco Use Cessation (MSC) is a survey measure that assesses different facets of providing medical assistance with smoking and tobacco use cessation. There are three components of the survey:
- Advising Smokers and Tobacco Users to Quit: Adults 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year
- Discussing Cessation Medications: Adults 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year
- Discussing Cessation Strategies: Adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies during the measurement year.
ICD-10-CM: general coding information
When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and comorbidities.
Details are required from the documentation to identify use, abuse or dependence of the substance.
Based on ICD-10-CM Coding Guidelines, when use, abuse or dependence of the same substance are documented in the medical record, only one code should be assigned based on the following hierarchy:
- If both use and abuse are documented, the code for abuse should be assigned
- If both abuse and dependence are documented, the code for dependence should be assigned
- If use, abuse and dependence are documented, the code for dependence should be assigned
- If both use and dependence are documented, the code for dependence should be assigned.8
Alcohol dependence and abuse
- Alcohol related disorders are classified to category F10-. An additional code for blood alcohol level (Y90.-) may be assigned, if applicable
- Alcohol abuse is classified under subcategory F10.-, Alcohol abuse
- Alcohol dependence is classified under subcategory F10.2-, Alcohol dependence
- Both categories alcohol abuse and alcohol dependence, are further subdivided to specify the presence of intoxication or intoxication delirium. Additional characters are also provided to specify alcohol-induced mood disorder, psychotic disorder, and other alcohol-induced disorders
- Codes in sub classification F10.23-, Alcohol dependence with withdrawal, provide additional detail regarding withdrawal symptoms such as delirium and perceptual disturbance
- Selection of codes “in remission” for categories F10-F19 requires the provider’s clinical judgement. The appropriate codes for “in remission” are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
- Toxic effect of alcohol is not classified to category F10 but to subcategory T51.0- instead.9
Drug dependence and abuse
ICD-10-CM classifies drug dependence and abuse in the following categories according to the class of the drug:
Cannabis related disorders
Sedative, hypnotic or anxiolytic related disorders
Cocaine related disorders
Other stimulant related disorders
Hallucinogen related disorders
Inhalant related disorders
Other psychoactive substance related disorders
- In most cases, fourth characters indicate whether the disorder is nondependent abuse (1), dependence (2), or unspecified use (9).
- Additional characters also provided to specify intoxication, intoxication delirium, and intoxication with perceptual disturbance.
- Patients with substance abuse or dependence often have related physical complications or psychotic symptoms. These complications are classified to the specific drug abuse or dependence, with the fifth or sixth characters providing further specificity regarding any associated drug-induced mood disorder, psychotic disorder, withdrawal, and other drug-induced disorders (such as sleep disorder).
Tobacco use and dependence
Category F17. - (nicotine dependence) codes are located in chapter 5 of the ICD-10-CM book.
The Excludes 1 note reminds that this is not the same diagnosis as tobacco use (Z72.0) nor the history of tobacco dependence (Z87.891). Therefore, the documentation will need to specifically discern between tobacco use and nicotine dependence.
The Excludes 2 note reminds to code tobacco use (smoking) during pregnancy, childbirth and the puerperium (O99.33-) and toxic effect of nicotine (T65.2-).
If the patient has been in contact with, or in close proximity to, a source of tobacco smoke, then Z77.22, Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic), need to be reported.
Tobacco abuse counseling is reported using code Z71.6 with the additional code for nicotine dependence (F17.-).
ICD-10-CM classifies nicotine dependence by substance:
- F17.20-, nicotine dependence, unspecified
- F17.21-, nicotine dependence, cigarettes
- F17.22-, nicotine dependence, chewing tobacco
- F17.29-, nicotine dependence, other tobacco product.9
Each category further breaks down the dependence using a sixth character to denote:
With other nicotine-induced disorders
- Opioid overdose. Overview of an epidemic. https://www.cdc.gov/drugoverdose/data/index.htm
- Current cigarette smoking among adults – United States, 2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6702a1.htm?s_cid=mm6702a1_w%20
- CDC. Health effects of cigarette smoking. Retrieved on 1/18/2018 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
- Treatment for co-occurring mental and substance use disorders. https://www.samhsa.gov/treatment
- What are treatments for tobacco dependence? Retrieved on 1/18/2018 from https://www.drugabuse.gov/publications/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence
- HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup RealSolutions in healthcare. Retrieved from https://providers.amerigroup.com
- NCQA updates quality measures for HEDIS 2018. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedisreg-2018?ArtMID=11280&ArticleID=85&tabid=2659
- ICD-10-CM Expert for Physicians. The complete official code set (2017). Optum 360
- Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. American Hospital Association, Chicago, IL.
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December 2018 Anthem Blue Cross Provider Newsletter - California