July 10, 2006

Coding for Substance Dependence and Abuse
For The Record
Vol. 18 No. 14 P. 40

Substance abuse is the regular or frequent use of an illegal or harmful substance that causes problems in some aspect of a person’s life. Substance dependence includes a group of behavioral and physiological symptoms that indicate the continual, compulsive use of a substance despite the problems related to the use of this substance. Increased amounts are needed to achieve the desired effect or level of intoxication so the patient’s tolerance for the substance increases. In addition, substance-dependent patients often experience physical signs of withdrawal when there is a sudden cessation of use.

AHA Coding Clinic for ICD-9-CM classifies these conditions as mental disorders and includes the following categories:

• 303, Alcohol dependence syndrome;

• 304, Drug dependence; and

• 305, Nondependent abuse of drugs.

Alcohol Dependence
Alcoholism is a chronic, progressive disease that involves a preoccupation with alcohol and impaired control over alcohol intake. Alcohol dependence is classified to ICD-9-CM category 303. A diagnosis of chronic alcoholism or unspecified alcohol dependence is classified to code 303.9x. A patient who has alcohol dependence and is currently intoxicated is assigned to code 303.0x, Acute alcoholic intoxication. Only one code from category 303 should be assigned during a given hospital stay.

Chronic alcoholism may lead to serious medical conditions. The following are common complications of alcoholism (The code assignment should be based on physician documentation and should only be coded as “alcoholic” if the physician documents it as an alcoholic complication or due to alcohol.):

• Alcoholic hepatitis (571.1);

• Cirrhosis (571.2);

• Gastritis (535.3x);

• Pancreatitis (577.0); and

• Cardiomyopathy (425.5).

The patient who is dependent on alcohol is also at an increased risk for cancer, heart failure, stroke, and hypoglycemia.

Alcohol Abuse
Patients with alcohol abuse (305.0x) have a problem with alcohol but do not display all the characteristics of alcoholism. They engage in excessive drinking that results in health or social problems, but they are not dependent on alcohol. Code 305.0x also includes the diagnosis of current intoxication.

Drug Dependence
Drug addiction may involve a psychologic and physical dependence to a drug and become such a large part of daily life that it interferes with the ability to interact with others normally. The signs and symptoms the patient experiences depends on the drug being used. Drug dependence is classified to category 304. The fourth-digit subcategory identifies the type of drug involved as follows:

• 304.0, Opioid type dependence;

• 304.1, Sedative, hypotic, or anxiolytic dependence;

• 304.2, Cocaine dependence;

• 304.3, Cannabis dependence;

• 304.4, Amphetamine and other psychostimulant;

• 304.5, Hallucinogen dependence;

• 304.6, Other specified drug dependence including glue sniffing and inhalant dependence; and

• 304.9, Unspecified drug dependence.

Code 304.7 is assigned when the patient is dependent to a combination of drugs and one of them is an opioid type drug. Assign code 304.8 when an opioid type is not involved in the combination of drugs abused.

Drug Abuse
Drug abuse refers to the dysfunction caused by the use of drugs when the person has not reached the dependence stage. Drug abuse is classified to codes 305.1x-305.9x. A diagnosis of drug seeking behavior with no other information documented is assigned to code 305.90 (AHA Coding Clinic for ICD-9-CM, 1999, third quarter, page 20).

Fifth-Digit Subclassification
The fifth-digit subclassification for substance abuse and dependence (303-305) identifies the pattern of use as follows:

• 0 – Unspecified;

• 1 – Continuous;

• 2 – Episodic; and

• 3 – In remission.

The appropriate fifth-digit code assignment is based on documentation in the medical record. “It is common for technical and professional personnel other than the attending physician to provide much of the documentation in facilities dealing with detoxification and rehabilitation, and it is appropriate to accept this documentation for the purpose of assigning fifth digits” (AHA Coding Clinic for ICD-9-CM, 1991, second quarter, page 11). If the documentation is not available in the medical record, the physician should be queried for clarification.

Principal Diagnosis Selection
Substance abuse or dependence often leads to psychotic symptoms such as withdrawal and hallucinations. Alcohol-induced mental disorders are classified to category 291, and drug-induced mental disorders are classified to category 292. The substance-related mental disorder condition should be sequenced as principal diagnosis with the alcohol/drug dependence sequenced as secondary diagnosis. Even if the patient experiences withdrawal after admission, the withdrawal code is sequenced as the principal diagnosis (AHA Coding Clinic for ICD-9-CM, 1994, third quarter, pages 13-14). If no substance-related mental condition is present, then the alcohol/drug dependence should be sequenced as the principal diagnosis if the patient is admitted for detoxification, rehabilitation, or both.

If a patient is admitted for a condition unrelated to the alcohol/drug dependence, follow the principal diagnosis selection guidelines. If a patient is admitted with a physical condition related to alcohol/drug dependence (eg, alcoholic hepatitis), the physical condition should be sequenced as the principal diagnosis. If a patient is pregnant and is admitted with an alcohol or drug related problem, the pregnancy code will be sequenced as the principal diagnosis, unless the physician specifically states the pregnancy is incidental.

Treatment
Treatment for substance dependence or abuse may require detoxification, rehabilitation, or both. Detoxification involves evaluating, observing, and monitoring patients with substance dependence. Thiamine and multivitamins may be given for nutrition, and the following medications may be administered:

• methadone;

• clonidine;

• long-acting barbiturates or benzodiazepines; and

• carbamazepine.

Detoxification may last four or five days.

Rehabilitation requires a written, structured program with the goal of replacing drug/alcohol dependence with activities that are nonchemical in nature (AHA Coding Clinic for ICD-9-CM, 1991, second quarter, pages 12-13).

Coding and sequencing for substance dependence and abuse are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

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