Nafheem Ameen
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compliance, coding, documentation, icd-10, icd-10-cm, Behavioral Disorders, Mental Disorders, Neurodevelopmental Disorders, F45.41, NIDA
In this blog, we’ll cover ICD-10-CM guidelines for correct code assignment for conditions such as pain due to psychological factors and mental and behavioral disorders due to psychoactive substance use.
Let’s first begin with pain. Pain Disorders may be classified as a mental disorder when psychological factors play the impact of the onset, severity, worsening, or maintenance of the pain. Pain can be acute, chronic or related to a psychological disorder. For pain that is exclusively related to psychological disorders, ICD-10-CM code F45.41 should be reported.
An ICD-10-CM code from G89 series should be coded when the documentation states that the pain is acute or chronic (and not due to psychological factors). The excludes 1 note under category G89 (chronic pain) states ICD-10-CM code from category G89 should never be reported together with ICD-10-CM F45.41.
When there is documentation supporting a psychological component for pain in a patient with acute or chronic pain, ICD-10-CM code F45.42 pain disorders with related psychological factors should be reported in addition to a code from category G89 pain, not elsewhere classified depending on the pain being acute or chronic.
Substance use disorders are often associated with patients with chronic pain. Some patients may even have a history of substance dependence which can make it challenging to make the correct code selection. It comes down to terminology and the provider’s documentation. ICD-10-CM code assignment for Mental and Behavioral Disorders Due to Psychoactive Substance are categorized into whether the substance use is; use abuse, dependence or in remission. There is a clinical difference between use, abuse, and dependence. The National Institute of Drug Abuse (NIDA) defines these categories as:
Use: the use of alcohol or other drugs to socialize and feel effects. Use may not appear abusive and may not lead to dependence.
Abuse: recurrent substance use resulting in; failure to fulfill obligations at work, home or school, puts the patient in a situation that is physically hazardous, results in legal problems or interpersonal problems
Dependence: also known as addiction, is a pattern of continuous use with 3 or more of the following symptoms: needing more to get “high”, taken in large amounts over a longer period of time, causes withdrawal symptoms when not used, use is an important social, occupational, or recreational activity, a great deal of time is spent using, obtaining, or recovering from its effects, and/or patient has desire or is unsuccessful to cut down use. Reference >
ICD-10-CM codes for the history of alcohol or drug dependence don’t exist in ICD‐10‐CM. Instead, these conditions are coded as “in remission.” In 2017, the Official Guidelines for Coding and Reporting for Mental and Behavioral Disorders due to psychoactive substance use was revised to read, “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.”
Plainly put…. a status of remission cannot be coded unless the provider’s documentation specifically states “in remission.” This status is based on the provider’s clinical judgment. It would not be appropriate to code this status based on a description of cessation or decreased use, or history of.
In addition to this change, there are inclusion terms for substance use, abuse, and dependence disorders which are in remission. These inclusions include:
- Mild, in early remission
- Mild, in sustained remission
- Moderate, in early remission
- Moderate, in sustained remission
- Severe, in early remission
- Severe, in sustained remission
These changes were made to mirror the terms of the Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM – 5).
When the provider documentation refers to use, abuse, and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), 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
Let’s go over some examples:
A 50‐year‐old female is currently receiving treatment for alcohol dependence, the patient also has a history of heroin use and dependence and is currently in remission. In this scenario, F10.20 Dependence, alcohol (without remission), and F11.21 Opioid dependence in remission can both can be reported.
The patient has a 10-year history of alcohol dependence and consumes high levels of alcohol daily. The patient was admitted for alcohol detoxification and rehabilitation. The patient began having withdrawal symptoms with delirium tremors. The correct code is F10.231 Alcohol dependence with withdrawal delirium.
In conclusion, it’s important to review the entire patient note to ensure you capture the proper code. Look for keywords or phrases that support the definition or inclusion term(s) and query the provider when in doubt.
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