ICD-9-CM and CPT coding update
By Therese M. Jorwic, MPH, WHIA, CCS, CCS-P
Two diagnoses that appear in too many records are alcohol and drug and addiction.
There is a difference between abuse and addiction.
Abuse is the misuse of a substance; it could lead to physical or psychological dependence. Addiction is dependence; stopping the use will cause withdrawal.
Alcohol is the oldest drug around, and there are from 10 million to 15 million alcoholics in the US. Alcohol is responsible for 79, 000 deaths each year, and 50% of all teen deaths are related to it.
Here is a look at the coding and how ICD-10-CM coding will differ from ICD-9-CM.
First, ICD-9-CM
In ICD-9-CM, the alcohol and drug codes are found in Chapter 5 (Mental, Behavioral and Neurodevelopment Disorders).
ALCOHOL (303)
The alcohol dependence syndrome codes begin at category 303 for alcohol dependence, and they include acute alcoholic intoxication in alcoholism (303.0) and other alcohol dependence (303.9)
A note here says to use an additional code for any condition associated with the alcoholism such as psychosis or cirrhosis of the liver.
DRUGS (304 and 305)
With drugs, there are two categories. They are 304 for dependent drug abuse and 305 for nondependent abuse. Alcohol abuse is also coded here at 305.0.
There is no note here saying to use another code for complications.
With drug dependence (304), there is a fourth digit to show the type of drug, and there are six specific types – opioids, sedatives, cocaine, cannabis, amphetamines, and hallucinogens (304.0 to 304.5).
There are also fourth digits to show other specified drugs, opioids with any drugs, combinations of non opioid drugs, and, of course, unspecified drugs.
The nondependent drug abuse codes (305) get used when the patient has voluntarily taken a drug that is causing harm to health or social functioning and there is no other diagnosis. The patient has abused the drug but is not dependent on it.
The first code here (305.0x) is for alcohol abuse, and that includes drunkenness and hangover. However, it excludes acute alcohol intoxication in alcoholism. That’s alcohol dependence and so is covered at 303.0 (acute drunkenness in alcoholism).
The second code (305.1x) is for tobacco dependence. (Yes, tobacco is a drug!)
From there the codes run to 305.9x, each showing the type of drug – cannabis, hallucinogens, sedatives, opioids, cocaine, amphetamines, antidepressants, and other (305.2 to 305.9).
PLUS FIFTH DIGITS FOR ALL
And then there are fifth digits. They are needed for all the 303, 304, and 305 codes, and it’s important to note that they must be based on the documentation.
0 – unspecified
1 – continuous – the abuse or dependence is ongoing and does not stop
2 – episodic – the abuse or dependence occurs sometimes but not all the time
3 – in remission – not a current problem
A V CODE FOR ALCOHOLISM
ICD-9-CM also has a V code – V11.3, for personal history of alcoholism. Use this if the documentation shows alcoholism history. There is argument that there is no such thing as a history of alcoholism because alcoholism is not curable but only goes into remission. However, that won’t be argued for long, because ICD-10-CM doesn’t have a code for personal history of alcoholism.
and now for ICD-10-CM
With ICD-10, alcohol and drug abuse once again fall into the chapter of Mental, Behavioral and Neurodevelopmental Disorders. The codes run from F10 through F19.
Here, each substance gets its own category, and the codes within each category distinguish between abuse and dependence. For example, F10 is for alcohol related disorders with subcategories F10.1 for alcohol abuse and F10.2 for alcohol dependence.
The categories cover alcohol, opioids, cannabis, sedatives and hypnotics, cocaine, other stimulants, hallucinogens, nicotine, inhalants, and other substances (F10 to F19).
From there, the codes get more specific.
For example, with alcohol abuse, F10.12 shows abuse with intoxication, and under that are three possibilities – uncomplicated (F10.120), with delirium (F10.121), and unspecified (F10.129).
There are also lots of combination codes here. An example is F10.1 for alcohol abuse followed by abuse with alcohol-induced mood disorder (F10.14), with anxiety disorder (F10.180), alcohol dependence with intoxication, uncomplicated (F10.22), and with withdrawal delirium (F10.23).
In ICD-9-CM, those secondary diagnoses have to be coded separately.
A NEW CONCEPT: USE
Also note three items explained in the guidelines:
Remission: In ICD-9-CM, remission is shown by a fifth digit. In ICD-10-CM, the codes themselves show the remission. For example, F10.21 shows alcohol dependence in remission, and F11.21 shows opioids dependence in remission. Be careful that the documentation says there is remission. A statement that the patient hasn’t had a drink for two years is not enough to support a remission code. The documentation has to say it.
Hierarchy: There is a hierarchy for coding use, abuse, and dependence. They fall in that order, with use at the bottom and dependence at the top, and it’s the top level that gets coded.
That’s important to know, because the physician could mention all three for the same substance, and only one code can be used. So following that order, the coding goes like this:
use + abuse = abuse
use + dependence = dependence
abuse + dependence = dependence
use + abuse + dependence = dependence
Use: ICD-10-CM also has a concept that’s not found in ICD-9-CM, and that is use. For example, F11.9 is for opioid use, F12.9 is for cannabis use, and F14.9 is for cocaine use.
Does use get coded every time the documentation mentions drinking?
No.
It only gets coded when the documentation says the drinking is associated with a mental or behavioral disorder that requires clinical care or evaluation. So if the documentation says the patient drinks alcohol, that doesn’t get coded. But if it says the patient drinks to the point of depression or judgment impairment, it does.
MORE COMBINATION CODES
Again, there are many combination codes for drug use and the mental disorders associated with it.
For example, F11.250 covers opioid dependence with opioid-induced delusions. And F11.251 covers the same with hallucinations.
By contrast, combination codes aren’t so prevalent with alcohol abuse. There are still situations where two codes are needed. An example is alcohol dependence with cirrhosis. ICD-10 still requires one code for the alcohol dependence and another for cirrhosis due to alcoholism. How the codes are listed will depend on which condition is the reason for the care.
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, is assistant professor of health information management at the University of Illinois at Chicago and senior consultant for MC Strategies in Atlanta.
