Health Information Management

Tip: Reporting tobacco use in ICD-10-CM

APCs Insider, May 22, 2015

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Tobacco use and dependence can increase a patient's risk of developing respiratory illness. ICD-9-CM has code 305.1 to report tobacco use disorder (tobacco dependence).
 
In ICD-10-CM, the term "smoker" defaults to dependence. Under the term "smoker," the ICD-10-CM Alphabetic Index directs coders to "see dependence, drug, nicotine." The important thing to note is that "smoker" goes to dependence, not use.
 
Although coders may not think of nicotine as a psychoactive substance, the codes for nicotine dependence are in the same range as other psychoactive substances. The guidelines are pretty clear when it comes to using codes in categories F10-F19.
 
The appropriate codes for "in remission," "with withdrawal," etc., within categories F10-F19 are based on provider documentation (see ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.5.c.).
 
More importantly, the patient must have a condition related to the substance use, abuse, or dependence, and it must meet the definition of a reportable diagnosis. The physician must document the relationship between the diagnosis and the substance use, abuse, or dependence.
 
This tip is adapted from “Start resolving ICD-10-CM questions" in the May issue of Briefings on APCs.



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