Q&A: Coding opioid use remission in light of medications

Q: Is a patient in remission from opioid use if he is currently taking methadone or suboxone? Can you code F11.11 in this situation?

A: Unfortunately, we cannot assume a patient is in remission with only the presence of medications documented, which means the code F11.11, Opioid abuse, in remission, cannot be assigned without clear documentation in the medical record by the provider.

The fact that a patient is on those types of medication, however, can be used as a clinical indicator when querying the provider for clarification of “in remission.”

As a reference, take a look at the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 5, for reference. It essentially says that remission codes “requires the provider’s clinical judgement” and that substance use disorder codes should only be assigned when they meet the criteria of being a reportable diagnosis.

Take a look at AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 2017, p.8. This Coding Clinic reiterates that codes for “in remission” can only assigned based on the provider’s documentation, “unless otherwise instructed by the classification.”

If you’d like to know more about the added codes for substance use, abuse, and dependence, take a look at the article I wrote in the November/December 2017 CDI Journal covering the Coding Clinic mentioned above.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.