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:
Complete code families applicable to History of Drug Use
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.
Compare key differences between these codes to ensure accurate selection
Code | Description | When to Use | Key Documentation |
---|---|---|---|
Z86.59 | Personal history of other mental and behavioral disorders | Use when documenting a resolved history of substance use with no ongoing treatment. |
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F11.21 | Opioid dependence, in remission | Use when the patient is in remission from opioid dependence and requires ongoing monitoring. |
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Z79.891 | Long term (current) use of opiate analgesic | Use for documenting prescribed opioid use without signs of misuse. |
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Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Essential facts and insights about History of Drug Use
Use when the patient is in remission from opioid dependence and requires ongoing monitoring.
Ensure provider documentation explicitly states 'in remission'.
Use for documenting prescribed opioid use without signs of misuse.
Ensure documentation supports therapeutic use without misuse.
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
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.
Clinical: Leads to inappropriate treatment plans., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims.
Educate providers on documentation standards., Implement EHR prompts for remission status.
Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit discrepancies., Data Quality: Affects accuracy of patient records.
Ensure documentation specifies whether the condition is resolved or in remission.
Incorrect coding can lead to audit findings.
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.
Common questions about ICD-10 coding for History of Drug Use, with expert answers to help guide accurate code selection and documentation.
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.
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