Documentation and Coding for Substance Use Disorders

Documentation and Coding for Substance Use Disorders

  • 04 Apr Off
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By Amanda Piern, CRC
Risk Adjustment Coder

ICD-10-CM significantly expanded the codes available for substance use disorders (SUDs). To properly code for these disorders, the diagnosis documentation should include the type of use disorder.

The ICD-10 index includes the following use disorders:

• Alcohol use
• Amphetamine-type substance use
• Cannabis use
• Cocaine use
• Hallucinogen use
• Inhalant use
• Opioid use
• Phencyclidine use
• Sedative
• Hypnotic
• Anxiolytic use
• Stimulant use (other) (unknown)
• Substance use (other) (unknown)

In each case, the provider must document the severity of the disorder as mild, moderate or severe. The Diagnostic and Statistical Manual 5th Edition (DSM5) provides guidelines to determine if the disorder exists and its severity.

DSM5 sets the following criteria for Substance Use Disorder: “SUD describes a problematic pattern of using a substance that results in impairment in daily life or noticeable distress.” Criteria are generally not considered met for those individuals taking substances solely under appropriate medical supervision. Positive responses to two or more of the following within 12 months are required.

1. Taking the substance in larger amounts and for longer than intended
2. Wanting to cut down or quit but not being able to do it
3. Spending a lot of time obtaining the substance
4. Failing to fulfill key role obligations due to use of substance
5. Craving or a strong desire to use substance
6. Continuing use of substance despite acknowledgment of persistent or recurrent physical or psychological difficulties from using substance
7. Continuing use despite persistent or recurring social or interpersonal problems caused or made worse by substance use
8. Stopping or reducing important social, occupational, or recreational activities due to substance use
9. Recurring use of substance in physically hazardous situations
10. Building up tolerance to the substance, requiring larger doses to get desired effect. (Does not apply for diminished effect when used appropriately under medical supervision)
11. Experiencing withdrawal symptoms after stopping use

Criteria for SUD Severity:

• None – substance use is present, but not a disorder (i.e., no problematic patterns)
• Mild – a minimum of two of the above criteria is required
• Moderate – four or five of the above criteria are required
• Severe – six or seven met criteria are required

Amanda Piern, CRC

Even when the use disorder is historical, the provider must document the severity. (See example below.)

Amphetamine Use Disorder in remission:

• F15.11 Amphetamine type Substance Use Disorder, Mild, in remission
• F15.21 Amphetamine type Substance Use Disorder, Moderate, in remission

ICD-10 provides additional codes for intoxication, delirium, remission, and induced disorders (anxiety, bipolar, depressive, major neurocognitive, mild neurocognitive, obsessive-compulsive, or sexual dysfunction) depending on the use disorder.