Find comprehensive information on documenting and coding a history of smoking for healthcare professionals. This guide covers clinical documentation best practices, ICD-10 codes for smoking status (current smoker, former smoker, never smoker), SNOMED CT concepts related to tobacco use and cessation, and resources for accurate medical coding and billing. Learn about assessing smoking history, including pack-years, frequency, and type of tobacco used, for improved patient care and accurate clinical records. Explore resources for smoking cessation interventions and support.
Also known as
Personal history of nicotine dependence
Indicates a past dependence on nicotine.
Nicotine dependence
Covers current nicotine dependence, including history if still active.
Tobacco use
Documents current tobacco use; may be relevant for ongoing exposure.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient currently a smoker?
Yes
Do NOT code history of smoking. Code current tobacco use (e.g., F17.200).
No
Did patient completely quit smoking?
When to use each related code
| Description |
|---|
| History of smoking |
| Nicotine dependence |
| Tobacco use disorder |
Coding Z72.0 (current smoker) or Z87.891 (personal history of nicotine dependence) requires specific documentation of current vs. past use. Unspecified status leads to inaccurate risk adjustment.
Relying solely on patient-reported history without provider validation can lead to coding errors. CDI queries can clarify discrepancies for accurate HCC capture.
Smoking history impacts other diagnoses (e.g., COPD, CAD). Failure to code these interconnected conditions impacts quality reporting and reimbursement.
Patient presents with a history of tobacco use, consistent with a diagnosis of History of Smoking (ICD-10: Z87.891, Other personal history of nicotine dependence). Social history reveals the patient reports a [number] pack-year history of cigarette smoking, starting at age [age]. The patient quit smoking [date or duration] ago. [Indicate current nicotine use status: The patient denies current tobacco or nicotine use. OR The patient reports continued use of cigarettes at [frequency] along with [other nicotine products, e.g., vaping, chewing tobacco]. OR The patient reports current use of nicotine replacement therapy, including [specify NRT, e.g., nicotine patches, gum, lozenges]]. Assessment includes evaluation of respiratory function, cardiovascular risk factors, and screening for smoking-related diseases such as lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular disease. Counseling on smoking cessation was provided, emphasizing the benefits of quitting and available resources. [If applicable: Patient expressed [level of motivation] to quit smoking and was provided with information on [specific cessation strategies, e.g., behavioral therapy, pharmacotherapy, support groups]. Referral to [specialist, e.g., pulmonologist, cardiologist, smoking cessation program] was made]. Patient education regarding the long-term health risks associated with smoking and the importance of regular follow-up was also addressed.