The epidemic of opioid use and overdose in the United States has reached epic proportions, prompting declaration of a national public health emergency and establishment of the President's Commission on Combating Drug Addiction and the Opioid Crisis.
According to the CDC, prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths, augmented by the increasing use of heroin. Opioid prescriptions nearly quadrupled from 1999 to 2010. In 2016, more than two million Americans had an addiction to prescription or illicit opioids. Since 2000, over 300,000 Americans have died of overdoses involving opioids. In 2015, there were 52,404 drug overdose deaths, almost two-thirds involving the use of opioids.
This crisis makes it imperative for clinicians to have detailed knowledge of opioid use disorders. Likewise, precise diagnostic and documentation skills are necessary to accurately reflect all of the circumstances and complications associated with opioid use.
The 2018 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) contains a large, complex set of combination codes to describe opioid use and its many manifestations, consequences, and related conditions. These codes are generally consistent with the clinical definitions and descriptions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
The preferred diagnostic term for problematic opioid use is opioid use disorder (OUD). Terms like “narcotics” and “drug or narcotic addiction” have fallen into disfavor because they may imply a moral judgment and perhaps criminal intent. According to DSM-5, the diagnosis of OUD requires a “problematic pattern of opioid use leading to clinically significant impairment or distress.”
The diagnosis and severity of OUD depend on the presence of at least two of 11 diagnostic criteria described by the DSM-5 (Table 1) that are virtually identical to its 11 alcohol use disorder criteria (see Coding Corner in the January and February 2018 ACP Hospitalist). However, the tolerance and withdrawal criteria are different—these are not applied to individuals taking prescription opioids solely under appropriate medical supervision. If such patients do not meet two or more other criteria, they do not have OUD.
Once a patient meets at least two criteria and has a diagnosis of OUD, severity is classified as mild, moderate, or severe based on the total number of criteria identified (Table 2). Opioid screening questionnaires may be used to identify patients with a high risk of OUD, but they do not establish a diagnosis.
It seems self-apparent that any illegal use of opioids intrinsically qualifies as OUD since several criteria are likely to be met, for example amount or duration of use that was not medically intended, inability to control use, time spent obtaining opioids, strong desire or urge to use, hazardous use, and psychosocial implications. Illegal use includes use of heroin as well as theft, diversion, or nefarious production or supply of prescription opioids.
Identification of OUD in remission is essential for documentation and coding purposes. DSM-5 defines remission as the absence of any OUD diagnostic criteria (other than craving/desire/urge for opioid) for at least three months. ICD-10-CM has two remission combination codes: code F11.11 for opioid abuse (mild OUD) and F11.21 for opioid dependence (moderate or severe OUD).
For patients with properly managed, prescribed opioid use without OUD, ICD-10-CM code Z79.891 for therapeutic long-term (current) use of opioid analgesics may be assigned. Code Z79.891 is also assigned for therapeutic methadone maintenance (with the exception of heroin dependence treatment, for which only an OUD code is used). If the patient's OUD is in remission during methadone maintenance, an “in remission” code is also assigned. If not, the applicable OUD code should also be used with Z79.891.
In summary, in response to the opioid epidemic, clinicians need detailed knowledge of OUD and related diagnostic and documentation for clinical management, correct coding, and data reporting. DSM-5 describes OUD as a problematic pattern of opioid use leading to clinically significant impairment or distress defined by the presence of at least two of 11 diagnostic criteria. It further classifies OUD by severity as mild, moderate, or severe.
Next month's column will address the definitions and coding implications of a number of conditions that may be opioid-induced.