Tips & Expertise: Substance Abuse and Poisonings, Adverse Effects, and Underdosings

Q: How do you code the use of e-cigarettes or vaping?
A: Coding Clinic, Second Quarter 2017: Page 28 addresses coding for the use of electronic cigarettes during smoking cessation. In that article, they advised to assign code F17.290, Nicotine dependence, other tobacco product. It should be noted that this advice is very specific to the use of e-cigarettes for smoking cessation. When a provider documents that a patient vapes, the first step is to determine if it should be coded by applying MEAT criteria. The second step is to identify the substance that the patient vapes and then code to the appropriate pattern of use (use, abuse, or dependence) and substance type.

Q: Which code should be used to report a newborn affected by the mother’s use of crystal meth: P04.16, Newborn affected by maternal use of amphetamines or P04.49, Newborn affected by maternal use of other drugs of addiction?
A: Assign code P04.49, Newborn affected by material use of other drugs of addiction when a newborn is affected by the mother’s use of crystal meth. The codes in subcategory P04.1 are only for reporting newborns affected by use of material medication.

Q: How should underdosing be coded if there is no change in the patient’s condition?
A: Per Coding Clinic, First Quarter 2022, page 36, assign a code for underdosing with a code for noncompliance with medication regimen. Even though there was not a change in the patient’s condition, the provider’s documentation that the patient stopped his medication is enough to warrant a code for underdosing.

Q: How do you code for a history of drug use, abuse, or dependence when the documentation does not state “in remission?”
A: With the exception of nicotine use disorders, which are classified differently, when the provider documents a history of substance use, abuse, or dependence, assign the code for use/abuse/dependence of the specified substance in remission. Coding Clinic, Second Quarter 2017: Page 27 states that history of drug dependence is classified by “type of drug, in remission.” The only exception to this rule is a history of nicotine, which is classified to code Z87.891, Personal history of nicotine dependence. It is important to note that although documentation of substance use is rather common, it should only be coded if the provider documents an associated mental or behavioral disorder or medical condition per OCG I.C.5.b.3.