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ICD-10 Coding for History of Drug Use(Z86.59, F11.21, Z79.891)

Complete ICD-10-CM coding and documentation guide for History of Drug Use. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Substance Use HistoryPast Drug Use

Related ICD-10 Code Ranges

Complete code families applicable to History of Drug Use

Z86.59Primary Range

Personal history of other mental and behavioral disorders

Used for documenting resolved substance use disorders with no ongoing treatment.

Mental and behavioral disorders due to psychoactive substance use

Covers active substance use disorders, including those in remission.

Long term (current) use of opiate analgesic

Used for documenting prescribed opioid use without abuse.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
Z86.59Personal history of other mental and behavioral disordersUse when documenting a resolved history of substance use with no ongoing treatment.
  • No treatment for substance use in the past 2 years
  • No active medications for substance use disorder
F11.21Opioid dependence, in remissionUse when the patient is in remission from opioid dependence and requires ongoing monitoring.
  • Negative urine drug screen for illicit opioids
  • Progress notes showing at least 12 months without cravings
  • Documented remission status
Z79.891Long term (current) use of opiate analgesicUse for documenting prescribed opioid use without signs of misuse.
  • Signed pain management contract
  • Consistent prescription fills
  • Absence of abuse or dependence terminology

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for history of drug use

Essential facts and insights about History of Drug Use

The ICD-10 code for history of drug use is Z86.59, used for documenting resolved substance use disorders.

Primary ICD-10-CM Codes for history of drug use

Personal history of other mental and behavioral disorders
Billable Code

Decision Criteria

documentation Criteria

  • Documented evidence of no substance use treatment in the past 2 years.

Applicable To

  • Resolved substance use disorders

Excludes

  • Current substance use disorders (F11-F19)

Clinical Validation Requirements

  • No treatment for substance use in the past 2 years
  • No active medications for substance use disorder

Code-Specific Risks

  • Misclassification of active remission as resolved history

Coding Notes

  • Ensure documentation specifies 'resolved' to avoid confusion with remission.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Opioid dependence, in remission

F11.21
Use F11.21 if the patient is in remission and requires ongoing monitoring.

Personal history of other mental and behavioral disorders

Z86.59
Use Z86.59 if the condition is resolved with no ongoing treatment.

Opioid use, unspecified

F11.90
Use F11.90 for recreational opioid use without dependence.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Drug Use to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z86.59.

Impact

Clinical: Leads to inappropriate treatment plans., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims.

Mitigation Strategy

Educate providers on documentation standards., Implement EHR prompts for remission status.

Impact

Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit discrepancies., Data Quality: Affects accuracy of patient records.

Mitigation Strategy

Ensure documentation specifies whether the condition is resolved or in remission.

Impact

Incorrect coding can lead to audit findings.

Mitigation Strategy

Regular training on documentation and coding standards.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for History of Drug Use, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Drug Use

Use these documentation templates to ensure complete and accurate documentation for History of Drug Use. These templates include all required elements for proper coding and billing.

Documenting resolved substance use

Specialty: Primary Care

Required Elements

  • Substance type
  • Last use date
  • Resolution confirmation

Example Documentation

Patient has a history of heroin use, last used in 2019, resolved with no treatment since.

Examples: Poor vs. Good Documentation

Poor Documentation Example
History of drug use.
Good Documentation Example
Patient with history of heroin use, last use 2019, resolved.
Explanation
The good example specifies substance, last use, and resolution, providing clarity.

Need help with ICD-10 coding for History of Drug Use? Ask your questions below.

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