One of the most notable changes was how documentation of substance use, abuse, or dependence and any associated mental or behavioral disorders are coded. Select Billable Codes to view only billable codes under F19. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together. Confusion can occur when there is conflicting documentation in the same medical record and a choice must be made between varying codes in the same code category. The Excludes1 note reminds you that this is not the same diagnosis as tobacco use Z72.
Open the final file labeled 'Tabular. A 'billable code' is detailed enough to be used to specify a medical diagnosis. These terms are the conditions for which that code is to be used. The fourth character is a type qualifier that further specifies the procedure type. The inclusion terms are not necessarily exhaustive. A 3-character code is to be used only if it is not further subdivided.
Substance Use Disorder refers to the overuse of, or dependence on, a drug leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. Determination of the correct code to report is based upon a hierarchical scale. . You will report signs, symptoms, manifestations, and comorbidities such as delirium, mood disorder, and hallucinations with one combination code from this subsection instead of needing to look for a second code. Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The fifth, sixth and seventh characters are not specified and always have the value None.
As you can see from the model, dependence is at the top of the hierarchy. Hierarchies are not new when it comes to coding. The third character specifies the root type. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. A type 2 Excludes note represents 'Not included here'. For example, codes for opioid dependence are found in category 304 Drug Dependence and codes for opioid abuse are found in category 305 Non-dependent Abuse of Drugs. Substance use disorder, also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impairment or distress.
In the subcategories for alcohol use and dependence, you will also find codes for states such as withdrawal, again providing one combination code, rather than needing a second code to report this condition. List of terms is included under some codes. The hierarchical scale is modeled below. Identify the correct specifiers and add the appropriate code extension. Therefore, the documentation will need to specifically discern between tobacco use and nicotine dependence. Use is at the bottom of the scale.
Although the term substance can refer to any physical matter, 'substance' in this context is limited to psychoactive drugs. An Excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. In addition, the excludes 1 notes found under various subcategories are consistent with the hierarchical organization outlined by guideline 5. Mental and Behavioral Disorders due to. Below dependence in status is abuse. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
These details can provide researchers with useful information as they look for better ways to care for patients with addiction. A type 1 Excludes note is a pure excludes. Examples include detoxification services and individual counseling. Part 1 will focus on guidelines and hierarchies. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7 th character, if applicable. Additional terms found only in the may also be assigned to a code.
For example, code category F11; here opioid related disorders is divided into 3 subcategories: F11. The next digit, indicated by the first x, signifies the problematic substance as shown in the table in Step 1 below. In these cases, only one code should be assigned to identify the pattern of use. Specifiers for Substance Coding Code 1 Abuse. Hierarchies A hierarchy is a system of organization in which items are ranked one above the other according to status. All digits after the decimal point add further specificity by indicating the nature and severity of the problem see table in Step 2 below. More specific codes: A more specific code should be selected.