Find comprehensive information on Drug Abuse (Substance Abuse, Substance Use Disorder) diagnosis including clinical documentation, medical coding, ICD-10 codes for drug dependence and harmful use, DSM-5 criteria, treatment options, and healthcare resources. Learn about accurate coding and documentation best practices for substance use disorders in medical records for optimized billing and reimbursement. Explore resources for healthcare professionals related to diagnosing and managing substance abuse and addiction.
Also known as
Mental and behavioral disorders due to psychoactive substance use
Covers various substance abuse disorders, including dependence and harmful use.
Poisoning by drugs, medicaments and biological substances
Describes poisonings and adverse effects from drug overuse or misuse.
Persons encountering health services
Includes codes for counseling and treatment for substance abuse.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the drug abuse related to alcohol?
Yes
Is it alcohol use disorder?
No
Which drug class is involved?
When to use each related code
| Description |
|---|
| Harmful drug use, dependence, or addiction. |
| Harmful alcohol use, dependence, or addiction. |
| Non-dependent abuse of substances, no physiological dependence. |
Coding drug abuse without specifying the substance leads to inaccurate reporting and reimbursement issues. Use specific ICD-10-CM codes.
Substance abuse often coexists with mental health disorders. Ensure accurate coding of both for proper risk adjustment and care planning.
Documenting and coding whether the substance abuse is in remission (early or sustained) impacts severity and resource allocation.
Q: What are the most effective evidence-based interventions for stimulant use disorder in adolescents, considering both individual and family therapy approaches?
A: Effective interventions for adolescent stimulant use disorder encompass both individual and family therapies. Individual approaches like Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) help adolescents develop coping skills, identify triggers, and build motivation for change. Family-based therapies, such as Multidimensional Family Therapy (MDFT) and Brief Strategic Family Therapy (BSFT), address family dynamics and communication patterns that contribute to or maintain substance use. Contingency Management (CM), using positive reinforcement for abstinence, has also demonstrated strong efficacy. The selection of interventions should be tailored to the individual adolescent's needs and the family's context. Explore how integrating these approaches can create a comprehensive treatment plan for improved outcomes. Consider implementing a stepped-care model to match intervention intensity to the adolescent's needs.
Q: How can clinicians accurately differentiate opioid withdrawal symptoms from other co-occurring conditions, like anxiety or depression, to ensure appropriate management and referral?
A: Differentiating opioid withdrawal from co-occurring anxiety or depression requires careful assessment. While some symptoms overlap (e.g., anxiety, insomnia), opioid withdrawal presents distinct features like muscle aches, dilated pupils, sweating, and gastrointestinal distress. The Clinical Opiate Withdrawal Scale (COWS) and the Subjective Opiate Withdrawal Scale (SOWS) offer standardized tools to quantify withdrawal severity. Critically, a thorough patient history, including substance use patterns and mental health history, is crucial for accurate diagnosis. Clinicians must also consider potential drug interactions. Learn more about the specific symptoms and timelines associated with opioid withdrawal to distinguish it from other conditions and ensure appropriate referral for medication-assisted treatment (MAT) or other evidence-based interventions.
Patient presents with signs and symptoms suggestive of a substance use disorder (SUD), also known as drug abuse or substance abuse. The patient reports [frequency] use of [substance name], meeting DSM-5 criteria for [specific substance use disorder, e.g., Opioid Use Disorder, Stimulant Use Disorder, Alcohol Use Disorder]. Clinical indicators include [list specific observed signs and symptoms e.g., intoxication, withdrawal, cravings, impaired control, social or occupational impairment, risky use, tolerance, physiological dependence]. Patient acknowledges [level of insight into substance use, e.g., limited insight, good insight, denial]. The patient's medical history includes [relevant past medical and psychiatric history, including prior treatment for substance use disorders, if applicable]. Family history is significant for [relevant family history of substance use or mental health disorders]. Physical examination reveals [relevant physical findings, e.g., elevated heart rate, dilated pupils, track marks, poor hygiene]. Assessment suggests [severity level of substance use disorder, e.g., mild, moderate, severe] based on the number of DSM-5 criteria met. Differential diagnoses considered include [list relevant differential diagnoses e.g., mood disorder, anxiety disorder, PTSD]. Initial treatment plan includes [detailed treatment plan including, e.g., brief intervention, motivational interviewing, referral to addiction specialist, medication-assisted treatment (MAT) options such as buprenorphine or naltrexone, detoxification, inpatient or outpatient rehabilitation, individual therapy, group therapy, family therapy, 12-step program, support groups, relapse prevention planning]. Patient education provided on the risks and consequences of substance abuse, available treatment options, and harm reduction strategies. Follow-up scheduled for [date] to monitor progress, assess treatment response, and adjust treatment plan as needed. ICD-10 code [appropriate ICD-10 code for specific substance use disorder] assigned. Medical necessity for treatment documented.