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ICD-10 Coding for History of Polysubstance Abuse(F19.20, F19.21, Z86.59)

Complete ICD-10-CM coding and documentation guide for History of Polysubstance Abuse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Polysubstance Use DisorderMultiple Substance Abuse History

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Related ICD-10 Code Ranges

Complete code families applicable to History of Polysubstance Abuse

F10-F19Primary Range

Mental and behavioral disorders due to psychoactive substance use

This range includes codes for substance use disorders, including polysubstance abuse and dependence.

Z86.59

Personal history of other mental and behavioral disorders

Used for documenting resolved substance use disorders with no current impact.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
F19.20Polysubstance dependence, currentUse when there is active dependence on three or more substances.
  • Documented tolerance and withdrawal symptoms
  • Positive UDS results
F19.21Polysubstance dependence, in remissionUse when the patient is in sustained remission for six months or more.
  • Clinician statement of remission
  • Negative UDS results over a sustained period
Z86.59Personal history of other mental and behavioral disordersUse when the disorder is resolved with no current treatment or impact.
  • No current treatment or impact
  • Documented history of resolved disorder

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for history of polysubstance abuse

Essential facts and insights about History of Polysubstance Abuse

The ICD-10 code for a history of polysubstance abuse, when resolved with no current impact, is Z86.59. For cases in remission, use F19.21.

Primary ICD-10-CM Codes for history of polysubstance abuse

F19.20
Polysubstance dependence, current
Billable Code

Decision Criteria

clinical Criteria

  • Presence of withdrawal symptoms and tolerance

Applicable To

  • Dependence on multiple substances

Excludes

Clinical Validation Requirements

  • Documented tolerance and withdrawal symptoms
  • Positive UDS results

Code-Specific Risks

  • Misclassification if not all substances are documented

Coding Notes

  • Ensure all substances are listed and documented.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Long-term opioid therapy

Z79.891
Use when patient is on long-term opioid therapy as part of treatment.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Polysubstance abuse, non-dependent

F19.10
Use when there is abuse without dependence.

Personal history of other mental/behavioral disorders

Z86.59
Use when there is no current impact or treatment.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Polysubstance Abuse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F19.20.

Impact

Clinical: Misrepresents patient's current status., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.

Mitigation Strategy

Verify current treatment status, Use correct remission codes

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.

Mitigation Strategy

Use F19.21 if the patient is still in remission and under monitoring.

Impact

Inadequate documentation of remission status.

Mitigation Strategy

Ensure clinician statements and monitoring results are documented.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for History of Polysubstance Abuse, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Polysubstance Abuse

Use these documentation templates to ensure complete and accurate documentation for History of Polysubstance Abuse. These templates include all required elements for proper coding and billing.

Patient in remission from polysubstance dependence

Specialty: Addiction Medicine

Required Elements

  • Substance use history
  • Current treatment status
  • Monitoring results

Example Documentation

Patient has been in sustained remission from heroin and cocaine dependence for 12 months, confirmed by negative UDS results.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has a history of drug use.
Good Documentation Example
Patient in sustained remission from heroin and cocaine dependence, confirmed by negative UDS for 12 months.
Explanation
The good example provides specific details and evidence of remission.

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