Opioid use, abuse, and overdose have become an epidemic that led to the President declaring it a national public health emergency. The National Institute on Drug Abuse reports that over 115 people die after an opioid overdose each day within the U.S., and according to the CDC, the economic burden of this epidemic within the United States totals to more than $78 billion each year.
Prescription drugs continue to play a significant role in the opioid crisis, and prescription opioids include medications like morphine, oxycodone, fentanyl, codeine, and hydrocodone. With opioid overdose and dependence at a crisis level in this country, clinicians must have detailed knowledge of this disorder. Likewise, it’s essential for pain management providers to be aware of the documentation and coding requirements when encountering cases of opioid use disorder.
Diagnosing Opioid Use Disorder
The proper diagnostic term used for opioid use that becomes problematic is now opioid use disorder, and the Diagnostic and Statistical Manual of Mental Disorders has grouped together opioid abuse, use, and dependence into what’s now referred to as opioid abuse disorder (OAD). To diagnose a patient with opioid use disorder, they may have a “problematic pattern of opioid use” that results in distress or impairment. This must be manifested by a minim of two of the following within a period of 12 months:
- Spending significant time taking, obtaining, or recovering from the effects of opioids
- Taking more of these drugs than they intended
- Continuing the use of these drugs despite social or relationship problems caused by the drug use
- Craving opioid drugs
- Trying to or wanting to control their use of opioids without success
- Increased tolerance for opioid drugs
- Symptoms of withdrawal when opioid drugs aren’t taken
- Failing to take care of important roles at work, school, or home due to the use of opioids
- Reducing or completely giving up activities due to opioid use
- Realizing that the use of opioids is causing psychological or physical problems, yet continuing to take them
- Using opioid drugs even when it’s considered unsafe physically
The severity level of opioid use disorder is determined based upon the number of symptoms the patient meets for diagnosis of OUD.
- Mild – Patient has 2-3 of the previously noted symptoms
- Moderate – Patient has 4-5 of the previously noted symptoms
- Severe – Patient has 6 or more of the previously noted symptoms
Once a patient has been diagnosed with opioid use disorder, they may be in sustained remission (12 or more months without using), early remission (3-12 months of not using), or no remission.
How to Code Opioid Use
Opioid use, abuse, and dependence are coded within category F11, and the codes you use are chosen based upon whether the patient is dependent on, abusing, or using opioids. Associated complications are also taken into consideration, and subcategories have various complications, so it’s essential to ensure every subcategory is reviewed to ensure you’re using the proper code. In general, F11.10 is used for opioid use disorder, mild and F11.20 is used for opioid use disorder that is either moderate or severe.
When determining which specific code to use when pain management providers documentation refers to the dependence, abuse, and use of opioids, it’s important to only use one code for the pattern of use. This should be done using this hierarchy:
- If there’s documentation for both abuse and use, then only the code for abuse should be used.
- If there’s documentation for both dependence and abuse, only the code for dependence should be used.
- If documentation is provided for dependence, use, and abuse, then only the code for dependence should be used.
- If there’s documentation for both dependence and use, only the code for dependence should be used.
Sometimes documentation provided by a provider may not be detailed enough for you to assign the proper code. In this case, you may need to ask for any additional missing information on the patient to help determine the correct code. Proper provider documentation is essential to accurately tracking opioid use disorder, so it’s critical that providers are education to avoid using the words “abuse” and “use” interchangeably. Providers should also avoid documenting with the words “abuse” or “use” when patients are genuinely dependent upon an opioid drug.
As a medical billing and coding specialist that specializes in pain management, M-Scribe understands many of the challenges that come with coding opioid use disorder and other related complications. Contact M-Scribe today to learn more about how we can help you with your billing and coding needs to maximize practice revenue.