ICD-10 Coding for History of Substance Abuse(F10.21, Z86.59)
Complete ICD-10-CM coding and documentation guide for History of Substance Abuse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Substance Abuse
F10-F19Primary Range
Mental and behavioral disorders due to psychoactive substance use
This range includes codes for substance use, abuse, and dependence, as well as remission states.
Personal history of other mental and behavioral disorders
Used for documenting a history of substance abuse when not currently active or in remission.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F10.21 | Alcohol dependence, in remission | Use when the provider documents alcohol dependence in remission. |
|
| Z86.59 | Personal history of other mental and behavioral disorders | Use when documenting a history of substance abuse without current use or remission. |
|
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 substance abuse
Essential facts and insights about History of Substance Abuse
Primary ICD-10-CM Codes for history of substance abuse
Decision Criteria
documentation Criteria
- Provider must document remission status explicitly.
Applicable To
- Alcohol dependence in sustained remission
Excludes
- Active alcohol dependence
Clinical Validation Requirements
- Provider documentation of remission
- Patient history of alcohol dependence
Code-Specific Risks
- Misuse if remission is not explicitly documented
Coding Notes
- Ensure remission status is clearly documented by the provider.
Z86.59 - Personal history of other mental and behavioral disorders
Use when documenting a history of substance abuse without current use or remission.
Applicable To
- History of substance abuse
Excludes
- Current substance use or dependence
Clinical Validation Requirements
- Documentation of past substance use without current use or remission
Coding Notes
Ensure that the history is clearly documented without current use or remission.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long-term (current) use of alcohol deterrents
Z79.891Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Substance Abuse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F10.21.
Impact
Clinical: Leads to inaccurate clinical records., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure provider specifies remission status, Use history codes if remission is not documented
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Ensure provider explicitly documents remission status before using remission codes.
Impact
Risk of audit if remission is coded without explicit documentation.
Mitigation Strategy
Ensure provider documentation explicitly states remission.
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 Substance Abuse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Substance Abuse
Use these documentation templates to ensure complete and accurate documentation for History of Substance Abuse. These templates include all required elements for proper coding and billing.
Documenting Substance Use History
Specialty: PsychiatryRequired Elements
- Substance(s) used
- Last use date
- Remission status
- Treatment history
- Current symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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