Find comprehensive information on heroin abuse diagnosis, including clinical documentation, medical coding (ICD-10 F11.20), signs and symptoms, withdrawal management, and treatment options. Learn about opioid use disorder, screening tools, and best practices for healthcare professionals documenting heroin dependence and addiction in patient records. Explore resources for accurate diagnosis and effective patient care related to heroin overdose, opioid dependence, and substance abuse treatment.
Also known as
Opioid Abuse
Covers heroin abuse and dependence, with and without induced mental disorders.
Opioid Dependence
Includes heroin dependence, with and without induced mental disorders.
Poisoning by Opioids
Describes poisoning by heroin and other opioids, covering various circumstances.
Opioid Use Disorder
Unspecified opioid use disorder, which could include heroin use.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is heroin use causing clinically significant impairment or distress?
Yes
Is it in remission?
No
Do not code heroin abuse. Consider other codes if applicable to clinical picture.
When to use each related code
| Description |
|---|
| Heroin dependence or abuse |
| Opioid use disorder |
| Opioid intoxication |
Using unspecified heroin abuse codes (e.g., F11.90) when more specific documentation supports F11.10 or F11.20, impacting reimbursement and data accuracy.
Failing to code co-occurring mental health or physical conditions (e.g., withdrawal, infections) associated with heroin abuse, understating severity.
Incorrectly coding history of heroin abuse (Z86.4) as active addiction (F11.10 or F11.20) or vice-versa, leading to inaccurate reporting and claims.
Q: What are the most effective evidence-based interventions for heroin use disorder in a primary care setting?
A: Integrating evidence-based interventions for heroin use disorder within primary care settings is crucial for improved patient outcomes. Medication-assisted treatment (MAT), particularly with buprenorphine or naltrexone, is the gold standard, combined with psychosocial interventions like cognitive behavioral therapy (CBT) or motivational interviewing (MI). Consider implementing a collaborative care model, including care coordination and patient navigation, to address the complex medical and psychosocial needs of patients with heroin use disorder. Explore how integrating telehealth can enhance access to these vital services, especially for patients in underserved areas. Learn more about the SAMHSA TIP for opioid use disorder for detailed guidance on implementing evidence-based practices.
Q: How can I differentiate heroin withdrawal symptoms from other conditions presenting with similar symptoms in the emergency department?
A: Differentiating heroin withdrawal from other conditions requires a thorough clinical assessment, including a detailed patient history and physical examination. While heroin withdrawal presents with symptoms such as muscle aches, nausea, vomiting, diarrhea, anxiety, and insomnia, these can overlap with other medical or psychiatric conditions. Look for specific signs like piloerection (goosebumps), pupillary dilation, and lacrimation (tearing). Urine toxicology screening can confirm opioid use, but consider that withdrawal may begin before the drug is cleared. Explore the Clinical Opiate Withdrawal Scale (COWS) as a standardized assessment tool to objectively quantify withdrawal severity and monitor patient progress. Consider implementing protocols for managing concurrent medical or psychiatric conditions that may complicate the clinical picture.
Patient presents with signs and symptoms consistent with heroin abuse, fulfilling DSM-5 criteria for opioid use disorder, specifically heroin. Presenting complaints include cravings for heroin, difficulty controlling heroin use despite negative consequences, and withdrawal symptoms when attempting to cease use. The patient reports using heroin intravenously multiple times daily. Physical examination reveals track marks on the antecubital fossa, pupillary constriction (miosis), and decreased respiratory rate. Patient acknowledges a history of opioid dependence and previous unsuccessful attempts at detoxification. Needle sharing practices were discussed, and risks of bloodborne infections such as HIV and hepatitis C were addressed. Urine drug screen is positive for opioids. Assessment includes heroin dependence, opioid use disorder, and intravenous drug use. Plan includes referral to addiction medicine specialist for medically supervised withdrawal (detoxification) and initiation of medication-assisted treatment (MAT) with buprenorphine-naloxone. Patient education provided on relapse prevention strategies, harm reduction techniques including needle exchange programs, and the importance of adherence to treatment. Follow-up appointment scheduled in one week to monitor withdrawal symptoms and MAT efficacy. ICD-10 code F11.20 is applied for opioid dependence, and Z79.891 is applied for long-term current drug therapy. CPT codes for the evaluation and management visit will be determined based on time spent and complexity of medical decision making.