Success Codes The Next Generation—Drug Use

The 21st Century Cures Act directed CMS to expand the risk-coding system to include additional mental health conditions.



We talked before that these changes are evolutionary, not revolutionary, but they will give you the chance to gain some additional risk-based revenue.



We also discussed how important it is to start coding these conditions now even though the changes are going to be phased in over three years starting in 2019.  Experience teaches that getting ahead of the curve is the key to outsized performance.



I simplified what you needed to know about risk-coding mental health conditions in this earlier blog post



Everything there is still accurate—and it’s still great.




But starting in 2019 conditions that previously were not associated with increased revenue will now get you additional credit.




Although lots of details still need to come out, here is what you, as a clinician or the supervisor of clinicians need to know.





Substance Dependence, Intoxication and Use


You’ll hear a lot about new classifications of “HCCs” in this group of diagnoses as well as the reassignment of risk-codes from one HCC to another.




Ignore all that.




Here’s what you need to know.




If a patient is dependent on an addictive substance, it’s a risk code.




If a patient is intoxicated on a substance, it’s a risk code.




If a patient is withdrawing from a substance (except Cannabis), it’s a risk code.




But if a patient has used an addictive substance, it’s not a risk code—until now.




Beginning in 2019, the diagnostic code associated with the mere use of an addictive substance will be associated with increased revenue.



Which substances?



  • Alcohol (ethanol) F10.90
  • Heroin, Opium and other opioids F11.90
  • Cocaine F14.90
  • Psychostimulants F15.90
  • (LSD) and other or unspecified hallucinogens F16.90



You will note that Cannabis is not on the list.




And no, the shot of cocaine the ENT gives your patient with a naso-pharyngoscopy doesn’t count, neither is the use of synthetic opioids to treat addiction (the therapeutic use of the substance doesn’t qualify)–nice try though, I like the way you think.




Otherwise, “use” is not defined, and as always with undefined codes, objective laboratory data is the for your diagnosis  A drug screen or serum level—it doesn’t have to pass the chain of custody test, just support your conclusion.




But if you don’t have objective data but you have still come to that conclusion, just document what led you in that direction.




Was it a behavior, some needle marks or simply the smell?




Address it, document it honestly and you’ll be fine.




Just using the substance now is associated with increased revenue.




You’re addressing it anyway, but now it’s well worth your time to start documenting it and submitting it as well.



It’ll be a win-win—-for everyone.








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