Outpatient CDI: Substance and mental health disorders

May 15, 2017 / By Camille Ruiz, RHIA

May is Mental Health month. It is a reminder to revisit outpatient CDI for substance disorders and mental health disorders. The Agency for Healthcare Research and Quality (AHRQ) statistics indicate one-fourth of U.S. adults have been diagnosed with mental health disorders and/or substance disorders. Studies for Medicare and Medicaid demonstrate that this dual diagnosis patient population accounts for the majority of healthcare expenditures and high utilization of healthcare services. This patient population visits the Emergency Department (ED) with a higher frequency than other populations and constitutes a high percentage of potentially preventable 30-day readmissions. Numerous health reform initiatives have helped reduce inappropriate visits and improve clinical outcomes and quality of care for patients with substance disorders and mental health disorders. 

It can be challenging for physicians to provide detailed documentation with such large outpatient volumes. Educating doctors as needed will reinforce the goal of clear, concise and accurate documentation. The following step-by-step guide, for example, provides education on documenting substance use/abuse:

1. Clarify the specific type of drug or substance, mode and usage specificity:

  • Use refers to taking a substance on a regular basis.
  • Abuse refers to the recurring or habitual use.
  • Dependence refers to continuous or compulsive use with the presence of symptoms such as tolerance and withdrawal. The physician must document dependence. Do not assume “Tobacco use” is tobacco dependence. 
  • The physician must document “in remission” which cannot be taken from nursing notes or other documentation per ICD-10-CM Official Guidelines for Coding and Reporting.

2. Assign blood alcohol levels when available.

3. The physician must link the condition to the substance. Look for opportunities to query.

Examples: Alcoholic cardiomyopathy or alcoholic liver disease, alcoholic dementia. 

4. Use combination codes for relationships between mental conditions and substance disorders.

Example: Patient with alcoholic dependence with alcohol-induced psychotic disorder, use combo code F10.259.

5. Determine substance-induced conditions such as poisoning or adverse effect when undetermined.

6. Clarify mental health disorder specific type, episode, episode type and severity when necessary.

Example: Bipolar Affective Disorder, Type I, recurrent, mixed, moderate

7. Patients with substance disorders are at risk for injury, infection and other medical conditions such as mental health disorders, cirrhosis, malnutrition, dysthymias, GI bleed, viral hepatitis, HIV, endocarditis, stroke, frequent falls, etc. Assign documented secondary diagnosis monitored, treated or impacting decision making.

8. Check conditions, histories and status on the active problem list impacting the current encounter such as:

  • Non-compliance if it causes an exacerbation or relapse of the medical condition being treated. Clarify under dosing, intentional or unintentional, or failure in dosing.
  • Suicidal/homicidal ideation, suicidal attempts and late effects of suicidal attempts
  • Intellectual, learning or developmental disorders.
  • Sleep disorders due to or associated with mental disorders
  • Eating disorders, malnutrition and low/high BMI
  • Sexual dysfunctions and any history of sexual abuse
  • Housing, educational, employment or income/financial status
  • Personal history status such as substance disorders, falls, abuse/neglect/trauma, exposure to second-hand smoke, self-harm, use of restraints ER
  • Refusal of treatment including screening, counseling and cessation
  • Assign feigning illness, malingering and drug seeking

9. Verify Present On Admission status, if undetermined.

10. Provide physician queries that are direct and non-leading.

Camille Ruiz is an outpatient CDI consultant at 3M Health Information Systems.