Updated on: November 28, 2016

The Opioid Epidemic: Abuse or Dependence

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Original story posted on: March 28, 2016
The week of May 15-21 is the federal Substance Abuse and Mental Health Services Administration’s National Prevention Week, which this year has a theme of “Strong as One: Strong Together.”

On May 18, Administration officials will focus on the prevention of prescription and opioid (synthetic narcotic pain medications) drug misuse. This topic has been a concern in many communities across the country during recent years. The National Institute on Drug Abuse (NIDA) wrote about this topic in May 2014, stating that it “affects health, social, and economic welfare of all societies.” The article also quantified the extent of this problem, as an estimated 26.4-36 million people misuse opioids.

The White House and Congress have agreed on one item this year – the severity of the problem of prescription opioid and heroin abuse. President Obama has earmarked an additional $1.1 billion in the 2017 budget to fight the issue in the U.S.

The Food and Drug Administration (FDA) will begin printing new warning labels on fast-acting opioid painkillers, noting that the drugs may cause a central nervous system reaction when taken with antidepressants and migraine medications. These opioid drugs include Oxycontin, Percocet, morphine, methadone, and street-based (illegal) heroin.  

And how is ICD-10 involved, you ask? From a clinical documentation improvement and coding perspective, the terms “abuse” and “dependence” are used interchangeably as they pertain to code implications. “Abuse” intimates that the patient can take the drug or not and continue to function, while “dependence” means that the patient requires the drug to function. In other words, a patient who is dependent will show withdrawal symptoms when they do not have the medication. For opioid abuse, the subcategory is F11.1, and for opioid dependence, the subcategory is F11.2. ICD-10-CM also has a subcategory for opioid use, which is F11.9.

The clinical documentation also should provide information regarding any associated condition such as intoxication, delirium, perceptual disturbance, delusions, hallucinations, etc. The clinical documentation also can include opioid-induced conditions such as sleep disorders, sexual dysfunction, psychotic disorder, or mood disorder.   

The specific documentation/codes could mean the difference of a complication/comorbid condition (CC) or not, which in turn impacts the reimbursement. Dependence is a CC with any manifestations, while abuse is only a CC when associated with intoxication and delirium, psychotic disorder with delusions, or psychotic disorder with hallucinations.

The presence of a CC could mean additional thousands of dollars under MS-DRGs. There are also some changes in the MS-DRG methodology in which detoxification procedure codes no longer impact the DRG assignment. Dependence without rehabilitation is assigned to MS-DRG 897 (RW 0.7231), while a patient who receives rehabilitation services is assigned MS-DRG 895 (RW 1.2435).

While the opioid epidemic is a problem for our health and well-being, it is also a concern from the coding and documentation perspective.
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.
Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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