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Differentiate Opioid Use, Abuse, Dependence to Pin Down Accurate ICD-10-CM F11 Code


Posted Feb 19, 2020
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All Blogs

Differentiate Opioid Use, Abuse, Dependence to Pin Down Accurate ICD-10-CM F11 Code

Posted February 19, 2020
Share: Share on Facebook Share on Twitter Share on LinkedIn

QUESTION: We are seeing more and more patients who have at least one substance abuse related diagnosis. We want to ensure that each claim accurately reflects the patient’s diagnosis and the services provided. Can you explain the difference between the opioid-related terms of opioid use, abuse and dependence and their associated ICD-10-CM F11.xx  opioid codes?

Springfield, MA Subscriber

ANSWER: Not all patients who use opioids have an opioid use disorder (OUD). To determine the presence and severity of OUD, you’ll need more than your ICD-10-CM manual. You’ll need access to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the American Psychiatric Association. Patients must exhibit two out of 11 diagnostic criteria for OUD to exist. The total number of criteria they meet determines whether the OUD is mild, moderate, or severe. If the OUD is mild, use ICD-10-CM code F11.1x (opioid abuse). If the OUD is moderate or severe, use code F11.2x (opioid dependence).

Note: If your facility uses its own opioid screening questionnaire as part of a quality improvement initiative — that’s great. But you can’t use that questionnaire to establish a diagnosis for coding purposes — you must adhere to the criteria from the DSM-5.

When coding for opioid use, abuse, and dependence, you’ll want to code only for the most severe condition. For example, if the clinician has documented both use and abuse, code only for abuse. If the clinician has documented both abuse and dependence (or all three conditions), code only for dependence. Here are your billable code options:

F11.1x Opioid abuse

F11.2x Opioid dependence

Remember: This use, abuse, dependence hierarchy applies the same way to vaping coding. Download this handy, printer-ready flow chart today so your staff can more easily and accurately capture the correct combination every time for vaping-related illnesses.

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Meet Your Writer

Heather Greene
RHIA, CIC, CDIP, CPMA, CPC
Managing Consultant at Health Care Performance Advisory Services

Heather is a member of the Health Care Performance Advisory Services division.  Heather has nearly 20 years of experience in the healthcare industry, with extensive experience working in a variety of key healthcare information management (HIM) roles. She assists hospitals in evaluating and improving their clinical documentation integrity (CDI) programs.  She also helps hospitals and physician practices in increasing their net revenues and lowering denials through improved clinical documentation and coding integrity. She provides coding and documentation consulting and training to improve clinical documentation integrity and coding accuracy. Heather is skilled at bringing trying information to life and incorporate relevant resources for clinical and administrative staff. Her presentation style is energetic, anecdotal and learner-focused, with a view not only to help participants improve their knowledge levels, but also enhance their willingness and ability to apply what they’ve learned in a practical setting. As a conscientious member of the healthcare community, Heather regularly attends conferences, seminars and takes advantage of many opportunities to interact with other nationally recognized HIM and coding experts where she can stay on top of the ever-changing regulations that impact the industry.  She is a member of American Health Information Management Association (AHIMA), American Clinical Documentation Integrity Specialists (ACDIS) and American Academy of Professional Coders (AAPC). She is currently on the CDI Summit Committee for AHIMA. Heather is a graduate of Eastern Kentucky University, with a B.S. in Health Information Management and has a Master of Business Administration from Midway College. She is a Registered Health Information Administrator (RHIA), Certified Inpatient Coder (CIC), Certified Documentation Improvement Professional (CDIP) Certified Professional Medical Auditor (CPMA), and Certified Professional Coder (CPC).  She also holds designations of Approved CDI and ICD-10-CM/PCS Trainer.