Substance Use Disorder*

Diagnostic Criteria, Documentation and Coding

According to the National Institute of Health (NIH), addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain. However, addiction is not a specific diagnosis in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which is the diagnostic manual used to establish mental disorders. The DSM-5 has replaced categories of substance abuse and substance dependence with a single category: substance use disorder, with three sub classifications—mild, moderate, and severe1. Although some healthcare professionals along with the ICD-10-CM are still using the obsolete terms, dependence or addiction.

Take into consideration the following criteria when establishing the diagnosis: 3,4,5

General Criteria:

1. Substance is often taken in larger amounts and/or over a longer period than the patient intended.

2. Persistent attempts were made, or one or more unsuccessful efforts, to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from effects.

4. Craving or strong desire or urge to use the substance.

5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued substance use despite having persistent or recurrent social or interpersonal problem caused or exacerbated by the effects of the substance.

7. Important social, occupational or recreational activities given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous.

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance

11. Withdrawal

More than one in four adults living with serious mental health problems also has a substance use problem. Substance use problems occur more frequently with certain mental health conditions, including2: Schizophrenia F20.9 (0.524), bipolar disorder F31.9 (0.309), and personality disorders F60.9 (0.309)**

Refer to the ICD-10-CM manual for more coding options for other complications like intoxication and withdrawal.

Substitute the last F code’s characters with the following characters if the patient suffers from any substance-related or induced problem:

Mood Disorder Characters - 14 Characters - 24

Deliriums Characters - 150 Characters - 250

Hallucinations

Sexual dysfunction

Characters - 151 Characters - 251

Characters - 181 Characters - 281

Sleep disorder Characters - 182 Characters - 282 1

Substance Use Disorder in Remission5

• Early remission: None of the criteria for substance use disorder have been met for at least 3 months but for less than 12 months

• Sustained remission: None of the criteria for substance use disorder have been met at any time during a period of 12 months or longer

The ICD-10-CM classifies both types of remissions under the same coding characters. Use the appropriate substance F code with .11 for mild disorders in remission and characters .21 for moderate and severe severities. Also, ICD-10-CM classifies “history of drug dependence” as “in remission”.

Substance use that does not meet criteria, 0-1 of the 11 criteria

The ICD-10-CM provides coding options for substance use that does not meet the severity criteria. However, these codes are to be used only when the substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the healthcare professional. These codes must never be used to identify recreational or social substance use without any related problem. These subcategories are: F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9- o F19.9-.

Caffeine Use Disorder

The caffeine use disorder should only be established if the use of this substance is causing any impairment in the patient’s health or require or affect patient care treatment or management. Examples include:

• “Patient suffers of insomnia and cannot decrease caffeine consumption…”.

• “Patient on bupropion, 30 days under the therapy, indicates that sometimes feels more anxious than normal and is harder to fall asleep since taking the drug. He was educated to cut down the caffeine consumption (currently 4-5 caffeine drinks a day) to only one drink. We will monitor…”.

• Limited or discontinue use of caffeine should be encouraged in patients with certain conditions like: hypertension, insomnia, anxiety, gastroesophageal reflux, gastritis, kidney problems, and others. Caffeine may also interact with certain prescribed drugs such as antidepressants and thyroid medications7, 8, 9, 11 .

Patient Treatment and Management10

• Toxic habits evaluation and medication reconciliation must be done to identify potential interactions and better course of treatment

• Behavioral counseling and psychotherapy

• Medication such as methadone and nicotine replacement therapies

• Medical devices and applications used to treat withdrawal symptoms or deliver skills training

• Evaluation and treatment for co-occurring mental health issues such as depression and anxiety

• Long-term follow-up to prevent relapse

HEDIS and Stars Rating programs recommend a patient evaluation within 14 days of the first intervention of the diagnosis, and two or more additional services within 30 days of the initial visit. This recommendation does not apply for patients with history or remission of the disorder6.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. Always refer to the ICD-10-CM manual for appropriate code assignment.

** HCC information and RAF weight is based on a community-nondual-aged member, please refer to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

1. NHI (rev. 2018, July). The Science of Drug Abuse and Addiction: The Basics. Retrieved from: https://www.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics

2. HHS. (2013, March 14). Mental Health and Substance Use Disorders. Retrieved from: https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders

3. Striley, C. L., Griffiths, R. R., & Cottler, L. B. (2011, Diciembre). Evaluating Dependence Criteria for Caffeine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621326/

4. Ogawa, N., & Ueki, H. (2007). Clinical importance of caffeine dependence and abuse. Psychiatry and Clinical Neurosciences, 61(3), 263-268. doi:10.1111/j.1440-1819.2007.01652.x.

Retrieved from: http://www.recoveryonpurpose.com/upload/Clinical%20Importance%20of%20Caffeine%20Dependence%20and%20Abuse.pdf

5. APA. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, Londres: American Psychiatric Association.

6. HEDIS (2018). Washington, DC: National Committee for Quality Assurance.

7. Sagon, C. (n.d.). Coffee for Health - Positive and Negative Effects of Caffeine. Retrieved from https://www.aarp.org/health/healthy-living/info-10-2013/coffee-for-health.html

8. Caffeine & Sleep Problems. (n.d.). Retrieved from https://www.sleepfoundation.org/articles/caffeine-and-sleep

9. Sheldon G. Sheps, M. (2019, January 26). What caffeine does to blood pressure.

Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/blood-pressure/faq-20058543

10. National Institute on Drug Abuse. (n.d.). Treatment Approaches for Drug Addiction.

Retrieved from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction

11. PDR. (n.d.). Bupropion hydrochloride - Drug Summary. Retrieved from: https://www.pdr.net/drug-summary/Wellbutrin-bupropion-hydrochloride-237