Substance use Disorder - The Pink Elephant in the Room!
Key Takeaways
Substance Use Disorder is a chronic, treatable medical disease. Document objectively, naming the specific substance(s) and severity using DSM-5-TR criteria.
Code with ICD-10-CM rules: apply the dependence-over-abuse hierarchy, and capture relevant states/complications (e.g., intoxication, withdrawal, delirium tremens, seizures). Do not bill with DSM codes.
Query when the record suggests SUD but lacks a clear diagnosis or severity. Keep queries non-leading and tie them to documented clinical indicators.
“Substance use disorders are associated with significant costs to society due to lost productivity, premature mortality, increased health care expenditure, costs related to criminal justice, social welfare, and other social consequences” (World Health Organization, 2022). In 2020 there were 93,000 drug overdose deaths and in 2022, there were nearly 108,000 drug overdose deaths in America. These statistics represent (almost) a staggering, 4-fold increase since 2002.
Numbers have increased significantly since the COVID pandemic according to the Centers for Disease Control and Prevention (CDC). During the pandemic there was an 18% increase in overdoses due to opiate use per the Overdose Detection Mapping Application Program (ODMAP). Substance use during COVID-19 pandemic: impact on the underserved communities - PMC
In ICD 10 CM substances of abuse are assigned a usage pattern as either “Use”, “Abuse” or “Dependence”. The current clinical model for evaluating substance use does not align with ICD 10 CM. Clinical Criteria definitions have emerged from the American Psychiatric Association (APA) and the American Society for Addiction Medicine (ASAM). Additionally, Substance Use Disorders got an overhaul as of January 1, 2022, in ICD 11.
The American Society of Addiction Medicine (ASAM) was founded in 1954. Its mission is to increase access and improve the quality of addiction treatment, educate physicians and the public, support research and prevention, and promote the appropriate role of physicians in the care of patients with addiction. asam-toolkit-speaking-same-language-2025-update.pdf
According to ASAM “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” “Clear language and terminology in medicine is critically important in communicating current understandings of disease, risk factors, diagnosis, prognosis, treatment options, health, and wellness to patients, the public, policy makers, media, and others.”
The American Psychiatric Association publishes the DSM, and it is in its fifth text revision, hence DSM- 5-TR. Terms depicting addiction are evolving, e.g., Substance Abuse is no longer used by DSM- 5-TR. DSM – 5 – TR classifies only to “use” and “dependence.” It does not crosswalk to ICD 10 CM and coders must be aware to not simply apply the DSM 5 TR code to a bill.
The DSM V-TR specifies cognitive, behavioral and physiological symptoms are included in a substance use disorder. A key trait of a substance use disorder is that the person continues to use the substance despite experiencing significant problems from their use. Substance use can change how the brain functions and these changes can persist long after the patient stops using the substance.
There are 11 criteria used by DSM V TR to diagnose substance use disorders and at least 2-3 must be true to arrive at a diagnosis. The eleven criteria are as follows: Using Larger Amounts over Longer Periods of time, Unsuccessful attempts to cut down, Excessive time spent using, Intense craving, Neglecting major life roles, Social and interpersonal problems, Giving up important activities, Risky/Hazardous Use, Physical and/or psychological problems, Tolerance, and Withdrawal. The scoring from this assessment identifies the severity of substance abuse as follows: Mild; 2-3 symptoms endorsed, Moderate; 4-5 symptoms endorsed, and Severe; 6 or more symptoms endorsed. The link here will take you to an assessment/checklist to download and share with your providers. GSC_DSM_5_ Checklist_8.24.13.docx
Given the social stigma associated with substance use and addiction, it is especially challenging to see a clear diagnosis assigned by clinicians. Often the diagnoses addressing substance use will vary between clinicians. When this happens, a query to the attending is needed. Queries must be based on findings in the medical record and must not be leading.
Talk to your clinicians about their preferred set of criteria and build assessment and audit tools according to the parameters they choose to use. ICD 10 CM criteria for 2026 have not changed in relation to the appropriate assignment of substance use. If both abuse and dependence are documented, assign only the code for dependence. If use, abuse and dependence are all documented, assign only the code for dependence. If both use and dependence are documented, assign only the code for dependence.
There are going to be significant changes to substance use codes when ICD 11 comes online in the United States. Gaining an understanding to the language, clinical documentation requirements and coding associated with this family of codes before this happens will be huge leg up going forward. Remember some of these diagnoses are assigned a Complication/Comorbid (CC) status and coding incorrectly could result in leaving money on the table.
This is not a diagnosis reserved only for psychiatric inpatient stays. This diagnosis has become prevalent across all encounters. We look at social determinants of health, and question substances used on taking a patient history, yet we do not translate this information into a code. There have been instances on audit where the patient has alcoholic related liver failure with no diagnosis of substance dependence, or they are on a Clinical Institute Withdrawal Assessment (CIWA) protocol without a diagnosis of substance use. The CIWA protocol is designed to quantify the severity of alcohol withdrawal symptoms, allowing healthcare providers to monitor patients and guide treatment decisions. It helps in identifying patients at risk of severe withdrawal complications, such as seizures or delirium tremens, and ensures timely intervention.
Coders are the personnel who have full access to the clinical record at the end of a patient stay or office visit. Your scrutiny of the data may place the issue of undiagnosed substance abuse in your path. Query the provider to achieve a definitive clinical picture when this occurs. In therapy the substance abuser is often looked at as the pink elephant in the room, something everyone sees but does not want to acknowledge. Time to remove that pink elephant!
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