Find comprehensive information on documenting a History of Drug Use diagnosis, including best practices for healthcare providers, clinical documentation guidelines, and relevant medical coding terms like substance use disorder, drug dependence, and remission status. Learn about screening tools, assessment methods, and standardized terminology for accurate and efficient medical record keeping related to past drug use. This resource covers essential information for physicians, nurses, and other healthcare professionals seeking guidance on proper documentation and coding for a history of drug use in patient charts.
Also known as
Mental, Behavioral due to Psychoactive
Covers disorders due to drug use, including abuse and dependence.
Problems related to lifestyle
Includes problems related to lifestyle such as past history of drug abuse.
Poisoning by Drugs, Meds, Bio Subs
While not history, captures poisonings which may indicate past use.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the drug use status current?
Yes
Is there dependence?
No
Was there ever dependence?
When to use each related code
| Description |
|---|
| History of drug use |
| Opioid use disorder |
| Stimulant use disorder |
Coding Z72.0 without specific drug details leads to inaccurate data, impacting quality reporting and reimbursement.
Confusing past drug use (Z86.4) with active addiction (F1x.2x) creates compliance and patient safety risks.
Insufficient clinical documentation to support drug use diagnosis causes coding errors and potential denials.
Patient presents with a history of substance use disorder, specifically mentioning past use of [Specific drug(s) used - e.g., heroin, cocaine, prescription opioids, cannabis]. The patient reports [Frequency of use - e.g., daily, weekly, occasional] use beginning approximately [Timeframe of first use - e.g., two years ago, during adolescence]. The patient describes [Route of administration - e.g., intravenous injection, intranasal insufflation, oral ingestion]. Consequences of drug use reported include [Specific consequences - e.g., job loss, relationship difficulties, legal issues, overdose requiring medical intervention]. Current symptoms related to drug use include [Current symptoms - e.g., cravings, withdrawal symptoms, anxiety, depression, insomnia]. Patient denies [Specific denials - e.g., current drug use, suicidal ideation, homicidal ideation]. The patient expresses [Patient's motivation level - e.g., motivation, ambivalence, resistance] towards treatment and recovery. Physical examination reveals [Relevant physical findings - e.g., track marks, nasal septal perforation, elevated blood pressure]. Mental status examination indicates [Mental status findings - e.g., alertness and orientation, anxious mood, intact cognition]. Assessment: History of drug use, [Specify specific substance use disorder - e.g., opioid use disorder, stimulant use disorder, cannabis use disorder], [Severity - e.g., mild, moderate, severe], [ICD-10 code]. Plan: Discussed treatment options including [Treatment options discussed - e.g., individual therapy, group therapy, medication-assisted treatment, residential treatment]. Patient education provided regarding risks and benefits of each option. Referral made to [Referral - e.g., addiction specialist, mental health counselor, detoxification facility]. Follow-up scheduled for [Date of follow-up]. Patient advised to return to the emergency department or contact their provider immediately if experiencing withdrawal symptoms or suicidal ideation.