Q&A: Reporting ICD-10-CM codes for drug and alcohol use in remission

CDI Strategies - Volume 16, Issue 43

Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?

A: Effective October 1, 2022, coders will find the following new ICD-10-CM codes for alcohol and drug use in remission:

  • F10.91, alcohol use, unspecified, in remission
  • F11.91, opioid use, unspecified, in remission
  • F12.91, cannabis use, unspecified, in remission
  • F13.91, sedative, hypnotic or anxiolytic use, unspecified, in remission
  • F14.91, cocaine use, unspecified, in remission
  • F15.91, other stimulant use, unspecified, in remission
  • F16.91, hallucinogen use, unspecified, in remission
  • F18.91, inhalant use, unspecified, in remission
  • F19.91, other psychoactive substance use, unspecified, in remission

Per the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 5, codes for drug and alcohol use disorders in remission cannot be assigned without clear documentation in the medical record by the provider.

The documentation must specify that the drug or alcohol disorder is in remission. This means that in the provider’s clinical judgment, the patient has achieved remission. “History of” codes describe conditions that are no longer being treated or monitored by the healthcare provider, which would not be the case with a disorder described as “in remission.”

Editor’s note: This article was originally published in JustCoding. This question was answered by Kimberly Cunningham, CCS, CPC, instructor for the Certified Coder Bootcamp programs at HCPro in Middleton, Massachusetts, during the webinar, “JustCoding’s 2023 ICD-10-CM Code Updates.”

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