You may be seeing more patients who report marijuana use as part of their social history but who have no related complaints. A reader recently asked if a code should be assigned for this. The answer, according to FPM contributing editor Cindy Hughes, CPC, CFPC, is no.
“The ICD-10 guidelines state that codes for psychoactive substance use disorders (e.g., F12.90, ‘Cannabis use, unspecified, uncomplicated’) should be reported only when the psychoactive substance use is associated with a physical, mental, or behavioral disorder and the relationship is documented in the physician's note for the encounter,” she writes in Coding & Documentation. “According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), patients with mild substance use disorders have two or three of 11 symptoms. Also note that the term ‘uncomplicated’ in the ICD-10 code descriptor should not be seen as prohibiting use of the code when mild substance use is documented and meets ICD-10 reporting criteria.”
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