ICD-10 Coding for Substance Use Disorders (Including Schedule IV/Controlled Substances)(F13.20, F15.20)
Complete ICD-10-CM coding and documentation guide for Substance Use Disorders (Including Schedule IV/Controlled Substances). Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Substance Use Disorders (Including Schedule IV/Controlled Substances)
F10-F19Primary Range
Mental and behavioral disorders due to psychoactive substance use
This range includes all substance use disorders, covering various substances including those classified under Schedule IV.
Poisoning by drugs, medicaments and biological substances
This range is used for coding poisoning and adverse effects related to drug use, including Schedule IV substances.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F13.20 | Sedative, hypnotic or anxiolytic dependence | Use when there is a documented dependence on sedatives, including benzodiazepines. |
|
| F15.20 | Stimulant use disorder, moderate or severe | Use for documented dependence on stimulants, including tramadol. |
|
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 Schedule IV drug use
Essential facts and insights about Substance Use Disorders (Including Schedule IV/Controlled Substances)
Primary ICD-10-CM Codes for roman numeral 4 drug use
Decision Criteria
clinical Criteria
- Presence of withdrawal symptoms and documented sedative use
Applicable To
- Dependence on benzodiazepines
- Dependence on z-drugs
Clinical Validation Requirements
- Documented history of sedative use
- Evidence of tolerance and withdrawal symptoms
Code-Specific Risks
- Misclassification if withdrawal symptoms are not documented
Coding Notes
- Ensure documentation specifies the type of sedative and the presence of dependence.
F15.20 - Stimulant use disorder, moderate or severe
Use for documented dependence on stimulants, including tramadol.
Applicable To
- Dependence on tramadol
- Dependence on certain stimulants
Excludes
- Cocaine dependence (F14.20)
Clinical Validation Requirements
- Documented stimulant use
- Evidence of significant impairment or distress
Coding Notes
Ensure documentation specifies the stimulant type and dependence.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Substance Use Disorders (Including Schedule IV/Controlled Substances) to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F13.20.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure thorough documentation of all symptoms and criteria.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit and compliance issues., Data Quality: Reduces data accuracy for clinical research.
Mitigation Strategy
Always document the specific substance and severity to use the most specific code.
Impact
Frequent use of unspecified codes can trigger audits.
Mitigation Strategy
Always document specific details to support the most specific code.
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 Substance Use Disorders (Including Schedule IV/Controlled Substances), with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Substance Use Disorders (Including Schedule IV/Controlled Substances)
Use these documentation templates to ensure complete and accurate documentation for Substance Use Disorders (Including Schedule IV/Controlled Substances). These templates include all required elements for proper coding and billing.
Chronic benzodiazepine dependence
Specialty: PsychiatryRequired Elements
- Substance type and duration
- Frequency and route of use
- DSM-5 criteria met
- Complications and severity
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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