February 1, 2016

Combating Opioid Addictions and Overdoses with Coded Data

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The statistics are striking: Between 2002 and 2013, heroin overdoses in the United States increased by 286 percent, according to a Centers for Disease Control and Prevention (CDC) report. In 2013 alone, more than 8,200 Americans died due to a heroin-related overdose.  

But heroin is only one of many highly addictive opioid drugs.

Vermont has found itself in the media spotlight recently due to its particularly sharp increase in opioid-related overdose deaths in the last decade. Since 2004, the annual incidence of such deaths has nearly doubled, according to the Vermont Department of Health. In his 2014 annual State of the State address, Vermont’s Governor, Peter Shumlin, referred to the issue as a “crisis bubbling just beneath the surface that may be invisible to many.” 

The good news is that medical codes can make a difference. That’s because these codes drive statistics that determine how important public health decisions are made. Coded data also drives research to help experts better understand potential causes of overdoses and addictions, as well as any complications. 

However, public health statistics are only as accurate as the coded data on which they’re based. Consider these three questions to ensure data integrity when coding opioid drug overdoses and addictions. 

1. Did the patient actually overdose on an opioid drug? If so, report a ICD-10-CM code from category T40.- as the principal diagnosis. Note that ICD-10-CM codes from this category denote the specific substance relating to the overdose, the intent of the overdose, and the type of encounter (i.e., initial, subsequent, or sequela). 

For heroin overdoses (T40.1-), there are four choices for intent: accidental, intentional self-harm, assault, and undetermined. Note that physicians may not know whether the overdose was accidental or intentional self-harm unless and until the patient is coherent. Even then, the information that the attending physician documents may not be accurate. It’s important to check the entire record for additional details and/or clarification. For example, a psychiatrist may provide more information related to the overdose once he or she speaks with the patient. Query for clarification if the psychiatrists’ documentation conflicts with that of the attending physician. Although this information regarding intent doesn’t affect the DRG, it certainly affects statistics that drive public interventions. For instance, an increase in the number of intentional heroin overdoses may help justify additional public health education or resources for the community.

2. Did the physician document opioid drug use, abuse, or dependence? If so, report an ICD-10-CM code from category F11.- as a secondary diagnosis (secondary to the overdose). Code F11.1- denotes abuse, code F11.2 denotes dependence, and code F11.9 denotes use

Note that physicians sometimes use the terms “use,” “abuse,” and “dependence” interchangeably. Always refer to the following hierarchy in the 2016 ICD-10-CM Official Guidelines for Coding and Reporting when choosing the correct descriptor: 

  • If both “use” and “abuse” are documented, assign only the code for abuse.
  • If both “abuse” and “dependence” are documented, assign only the code for dependence.
  • If “use,” “abuse,” and “dependence” are all documented, assign only the code for dependence.
  • If both “use” and “dependence” are documented, assign only the code for dependence.

Note that codes in the F11.- category are also combination codes that require additional codes to capture any associated complications, including:

  • Delirium
  • Perceptual disturbance
  • Mood disorder
  • Psychotic disorder
  • Delusions
  • Hallucinations
  • Sexual dysfunction
  • Sleep disorder
  • Withdrawal
  • Intoxication

Although coders aren’t required to capture the specific complication (e.g., erectile dysfunction or insomnia), doing so certainly helps in terms of research and data analysis.

Also note that the drug on which the patient overdoses may be only one of several drugs that he or she is using, abusing, or dependent on. According to the CDC, more than nine in 10 people who use heroin also use at least one other drug. Most use at least three other drugs.

Forty-five percentof people who use heroin are also addicted to prescription opioid painkillers. Report as many substance use codes as necessary to capture the complete picture of the patient’s drug use. 

3. Did the physician document any other associated manifestations? Patients who suffer heroin or other opioid overdoses also typically experience one or more of the following conditions, some of which carry considerable weight in the APR-DRG system:

  • Acute respiratory failure
  • Acute kidney failure
  • Coma
  • Liver failure 

It’s important to capture these conditions when they’re linked to the drug use.

Importance of physician education

Statistical data depends on coded data, and coded data depends on documentation specificity. Encourage physicians to: 

  • Document the intent of the overdose carefully.
  • Choose one term (use, abuse, or dependence) to use throughout the note consistently.
  • Document any complications.
  • Identify any and all other drug use, abuse, or dependence.
  • Document any manifestations and link them to the drug use (when appropriate).

ICD-10 gives us the opportunity to improve public health intervention related to drug abuse. For instance, we already know that many people abuse or become dependent on alcohol to address their bipolar disorder. Where are the other links between mental illness and drug use, abuse, or dependence? It’s about finding and targeting the root cause of drug problems, and coded data can help us get answers. 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.

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