Find information on opioid dependence in remission, including clinical documentation requirements, ICD-10-CM diagnosis codes (F11.21, F11.22, F11.23), DSM-5 criteria, and treatment resources for healthcare professionals. Learn about appropriate medical coding for sustained remission, early remission, and opioid use disorder in remission. Understand the difference between remission and recovery and explore best practices for accurate clinical documentation related to opioid dependence in remission.
Also known as
Opioid dependence, remission
Diagnosis for opioid dependence that is currently in remission.
Opioid abuse, remission
Diagnosis for opioid abuse that is currently in remission.
Prsnl hx of opioid abuse
Indicates a past history of opioid abuse, now resolved.
Prsnl hx of opioid dependence
Indicates a past history of opioid dependence, now resolved.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the opioid dependence currently in remission?
Yes
Is remission early or sustained?
No
Is opioid use active?
When to use each related code
| Description |
|---|
| Opioid dependence, now in remission. |
| Opioid use disorder, mild. |
| Opioid use disorder, moderate. |
Insufficient documentation specifying the timeframe of opioid abstinence to support remission status coding (F11.21).
Incorrectly coding active opioid dependence (F11.20) when documentation supports remission, or vice versa, due to unclear clinical picture.
Lack of detailed clinical evidence, therapy participation, or psychosocial assessments to substantiate the opioid dependence remission diagnosis.
Patient presents today for follow-up regarding opioid dependence treatment. The patient reports sustained remission from opioid use disorder, now exceeding 12 months of abstinence from opioid analgesics including heroin, prescription pain medications, and illicit opioid analogs. This remission is supported by consistent negative urine drug screens and the patient's self-reported adherence to their prescribed medication-assisted treatment (MAT) with buprenorphine-naloxone. The patient denies cravings, withdrawal symptoms, or any recent opioid use. They demonstrate improved psychosocial functioning, including stable housing, employment, and positive family relationships. Mental status examination reveals clear sensorium, appropriate affect, and intact thought processes. Diagnosis: Opioid Dependence in Sustained Remission (F11.21). Treatment plan includes continuation of current buprenorphine-naloxone therapy, ongoing individual therapy focusing on relapse prevention strategies, and participation in support groups. Prognosis is good with continued adherence to the treatment plan. We will continue to monitor for signs of relapse and adjust treatment as needed. The patient understands the risks of relapse and the importance of ongoing support. Future appointments are scheduled for continued medication management and psychosocial support. This encounter addresses opioid addiction treatment, opioid use disorder, substance abuse disorder, remission criteria, medication-assisted treatment, buprenorphine, naloxone, relapse prevention, recovery, and behavioral health.