Opioid Pattern Variations Highlight Need for Careful ICD-10 Coding

August 29, 2017 2:54 pm

Medical record codes are used to monitor national opioid addiction and oversode death patterns. Coded data has a direct impact on important public health decisions.

Question: With so much attention on opioid addiction right now, what are some areas coders should be aware of to ensure they capture data accurately?

Answer: A recent Vital Signs report released by the Centers for Disease Control and Prevention (CDC) notes a wide variation in opioid prescriptions among U.S. counties. While the national average is trending downward, opioid prescribing could be up to six times higher depending on where you live, according to the July 2017 report. Researchers found that characteristics of counties with higher opioid prescribing include a higher percentage of white residents, more dentists and primary care physicians, and larger numbers of patients with diabetes, arthritis, or disability. However, variations and inconsistencies abound nationwide.

Along with important prescribing data from the CDC, medical record codes are used to monitor national opioid addiction and overdose death patterns. Coded data drives statistics on which important public health decisions are based. In addition, coded data fuels research to better understand potential overdose and addiction causes as well as complications.

Healthcare organizations should consider the following three steps to ensure proper ICD-10 coding of opioid drug addiction and overdose.

Opioid Overdose: Check Intent

Codes within the ICD-10-CM category T40 are being used to denote specific substances related to the overdose, intent, and type of encounter—initial, subsequent, or sequela. It is important to check the entire record for details and clarification to determine if the overdose was accidental, intentional self-harm, assault, or undetermined.

Because physicians may not know patient intent right away, thorough documentation reviews are warranted. For example, patients may be incoherent upon admission, and further psychiatric evaluations may be needed to reveal the full story. In cases where psychiatrists’ documentation conflicts with that of attending physicians, documentation queries are warranted. While overdose intent doesn’t impact the DRG, correct coding ensures accurate public reporting for public health education or expanding resources in communities.

Abuse, Dependence, or Use: Get Clear

Physicians sometimes use the terms abuse, dependence, and use interchangeably. However, ICD-10-CM category F11 includes a separate code for each.

  • F11.1 – Abuse
  • F11.11 – Abuse in remission (early) (sustained)
  • F11.2 – Dependence
  • F11.21 – Dependence in remission (early) (sustained)
  • F11.9 – Use

Coders should always refer to official guidelines for coding and reporting (i.e., ICD-10-CM Official Guidelines for Coding and Reporting FY 2017  and 2018 ICD-10 CM and GEMs ) when choosing the correct descriptions based on the following specifications:

  • If both use and abuse are documented, assign only the code for abuse.
  • If both abuse and dependence are documented, assign only the code for dependence.
  • If use, abuse, and dependence are all documented, assign only the code for dependence.
  • If both use and dependence are documented, assign only the code for dependence.

These guidelines will be updated for FY18 with the addition of F11.11 and F11.21 (remission codes). New coding advice will be shared in the AHA Coding Clinics However, as of this article’s publication date, coders should continue to reference Coding Clinic, Second Quarter 2017, page 27, which addresses drug dependence in remission.

Note that codes in the F11 category are also combination codes that require additional codes to designate any associated complications such as delirium, hallucinations, or sleep disorder. These additional complication codes also help support research and data analysis for opioid addictions and overdoses.

Finally, more than one drug may be involved. According to the CDC, most drug overdose patients use at least three other drugs. Therefore, report as many substance use codes as required to paint complete pictures of patients’ various drug uses.

Capture Associated Manifestations

Opioid overdose patients also typically experience other associated manifestations such as acute respiratory failure, acute kidney failure, coma, and liver failure. These conditions carry considerable weight in the APR-DRG system and should be captured.

Finally, educate physicians to thoroughly document opioid cases and uncover any underlying mental illnesses or disorders. People with mental health disorders represent 16 percent of the U.S. population and receive more than 50 percent of the 115 million opioid prescriptions in the nation annually, according to a report in the July-August 2017 issue of the Journal of the American Board of Family Medicine . Improving pain management for this population is critical to reducing dependency.

Assist Public Health Interventions

Statistical data depends on coded data, and coded data depends on clinical documentation specificity. This is true for all cases, but particularly true for opioid addictions and overdoses.

With his state making national news for the highest rates of annual overdose deaths, Vermont Gov. Peter Shumlin stated that opioid addictions are a “crisis bubbling just beneath the surface that may be invisible to many.” Careful ICD-10 coding for opioid-related conditions is paramount to combating this crisis. When these cases are coded correctly, researchers can identify patterns, trends, and links in national opioid abuse, overdose, and death.


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