Find information on documenting and coding a history of polysubstance abuse in healthcare settings. Learn about clinical documentation improvement, ICD-10 codes for polysubstance dependence and abuse, DSM-5 criteria, substance use disorder treatment, and best practices for accurate medical coding related to a past history of drug abuse and alcohol abuse. This resource provides guidance for clinicians, medical coders, and healthcare professionals on proper terminology and documentation for patients with a history of multiple substance use.
Also known as
Mental/behavioral dis. due to mult. drug use
Covers disorders caused by combined use of multiple substances.
Personal history of psychoactive substance abuse
Indicates a past history of abuse, but not current dependence or use.
Mental/behavioral dis. due to psychoactive substance use
Includes a wider range of substance-related disorders, including polysubstance use.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there continued use or dependence?
Yes
Which substances?
No
Full remission?
When to use each related code
| Description |
|---|
| Polysubstance abuse |
| Opioid use disorder |
| Stimulant use disorder |
Coding F19.20 requires specific substance documentation. Lack of detail leads to coding errors and claim denials.
Distinguishing active abuse (F19.20) from history (F19.25) is crucial. Incorrect coding impacts severity and reimbursement.
Polysubstance abuse often coexists with mental health disorders. Incomplete documentation can lead to missed CC/MCC capture.
Patient presents with a history of polysubstance abuse, meeting DSM-5 criteria for this diagnosis. The patient reports a long-term pattern of concurrent or sequential use of multiple substances including alcohol, opioids, and stimulants. Onset of use began in adolescence, escalating in recent years. The patient acknowledges significant impairment in social, occupational, and recreational functioning due to substance use, including job loss, strained family relationships, and legal issues related to driving under the influence. Symptoms include cravings, withdrawal symptoms upon cessation, and continued use despite negative consequences. Physical examination reveals evidence of past intravenous drug use with track marks present. Mental status examination reveals anxious mood, psychomotor agitation, and impaired judgment. Patient denies suicidal or homicidal ideation. Assessment includes substance use disorder, polysubstance dependence, addiction treatment, and relapse prevention. Plan includes referral to substance abuse counseling, individual therapy addressing underlying psychological factors contributing to substance use, and consideration for medication-assisted treatment (MAT) options such as naltrexone or buprenorphine. Patient education provided on risks of continued polysubstance use, harm reduction strategies, and available community resources. Follow-up appointment scheduled to monitor progress and adjust treatment plan as needed. Differential diagnosis includes mood disorders, anxiety disorders, and personality disorders. Prognosis guarded but improves with adherence to treatment recommendations. ICD-10 code F19.20 will be used for billing purposes.