Q&A: Documentation of substance use “disorder”

Q: The coders at our facility recently asked CDI to teach the providers to write ethanol (EtOH) use “disorder” or cocaine use “disorder,” so that they can code it to EtOH abuse and cocaine abuse. Do you agree with this request from the coders? Our facility discourages providers from “labeling patients with the word abuse” so providers will never write “abuse.” The previous CDI lead has been informed by the psychiatric department to not to query providers about “abuse.”

A: If you look at the codes related to alcohol abuse within the code set (F10.1), you will see the wording of “alcohol use disorder” listed as an inclusion term. It will map to the code related to alcohol abuse. The patient’s claim will state EtOH abuse. Your coding staff is teaching this to providers as a “work around” that allows them to code abuse. The providers may not be aware that this wording will lead to the assignment of a code indicating substance abuse—and it appears they are trying to avoid that term.

That said, if the patient is demonstrating the level of abuse, it should be well documented and reported. We are not doing patients any favors by inaccurately reporting their level of substance consumption. All providers caring for the patient should be well aware of the patterns of substance consumption especially related to the levels of abuse or dependence. If providers are not using the correct terms it could be detrimental to the patient.

I would suggest that the education given to your medical staff should be related to the clinical indicators of substance abuse and dependence. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5), provides a reference for substance abuse. Substance dependence can easily be found within medical literature as it is considered a medical condition.

Ultimately, there should be coordination between coding/CDI, medical staff, and psychiatry to ensure everyone is consistently using the definitions correctly and that they are applied appropriately to the patients.  

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.