Find information on Substance-Induced Mood Disorder including clinical documentation, diagnostic criteria, and medical coding. Learn about the connection between substance use and mood disturbances, differential diagnosis considerations, and appropriate ICD-10-CM codes for accurate billing and healthcare reimbursement. This resource covers Substance-Induced Depressive Disorder, Substance-Induced Bipolar Disorder, and Substance-Induced Anxiety Disorder for healthcare professionals involved in diagnosis, treatment, and medical coding. Explore resources for accurate clinical documentation and coding compliance.
Also known as
Mental and behavioral disorders due to psychoactive substance use
Covers various mental disorders caused by substance use, including mood disorders.
Mood affective disorders
Encompasses mood disorders like depression and bipolar, some of which can be substance-induced.
Poisoning by drugs, medicaments and biological substances
Includes poisoning that may contribute to or trigger mood disturbances.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the mood disorder due to substance intoxication?
Yes
Specify substance
No
Is it due to substance withdrawal?
When to use each related code
| Description |
|---|
| Mood changes due to substance use |
| Bipolar I Disorder |
| Major Depressive Disorder |
Coding Substance-Induced Mood Disorder without specifying the causative substance leads to inaccurate reporting and potential claim denials. Use F1x.xxx codes appropriately.
Failing to code both the substance use disorder and the mood disorder independently can result in underreporting severity and missed comorbidity adjustments for reimbursement.
Insufficient provider documentation linking the substance use to the mood disturbance creates audit risk and may lead to coding queries and claim rejections. Ensure clear causal link.
Patient presents with symptoms consistent with Substance-Induced Mood Disorder (SIMD). The patient reports experiencing [specific mood symptoms, e.g., depressed mood, marked anxiety, mania, or mixed features] temporally related to the use of [specific substance, e.g., alcohol, opioids, cannabis, stimulants, or sedatives]. Onset of mood disturbance occurred [timeframe of onset relative to substance use, e.g., during intoxication, withdrawal, or after cessation]. Symptoms include [list prominent symptoms, e.g., insomnia, irritability, psychomotor agitation or retardation, fatigue, appetite changes, feelings of worthlessness or guilt, difficulty concentrating, and suicidal ideation]. The clinical picture is not better explained by a primary mood disorder that is not substance-induced. Evidence supporting this includes [evidence against a primary mood disorder, e.g., no prior history of mood disorder, symptoms resolve with abstinence, or symptoms clearly worsen with substance use]. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Differential diagnoses considered include [list relevant differential diagnoses, e.g., primary mood disorders, other substance-induced disorders, medical conditions]. Assessment includes review of substance use history, mental status examination, and consideration of laboratory testing to rule out other medical conditions. Treatment plan includes [treatment strategies, e.g., substance use disorder treatment, psychotherapy such as cognitive behavioral therapy (CBT) or motivational interviewing, and pharmacotherapy if indicated with medications such as antidepressants or mood stabilizers]. Patient education provided on substance-induced mood disorders, medication management, and relapse prevention. Follow-up scheduled to monitor symptom resolution, medication efficacy, and abstinence. ICD-10 code [appropriate ICD-10 code, e.g., F1x.xxx] assigned. CPT codes for today's visit include [relevant CPT codes for evaluation and management, e.g., 9921x].