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How physician documentation and coding can combat the opioid crisis


Experts agree that when it comes to combatting the opioid crisis, physicians need to shift their mindset and start focusing on data integrity.

More than 10 million people misuse opioids every year, according to the National Center for Drug Abuse Statistics. Overdose deaths involving opioids increased 519.38% from 1999 to 2019. These and similarly alarming statistics are why the U.S. Department of Health and Human Services (HHS) officially declared the opioid crisis a public health emergency in 2017.

More recently, HHS announced it will provide nearly $1.5 billion to states and territories to help address the opioid epidemic. The grant funding opportunity will be available through the Substance Abuse and Mental Health Services Administration (SAMHSA). Meanwhile, the Centers for Disease Control and Prevention (CDC) published updated draft guidance on when to initiate opioid prescribing, selection and dosage, duration and follow-up, and assessing risks and addressing harm.

It’s all part of an effort to support physicians in the quest to help patients struggling with opioid use disorder. At the heart of these efforts? Coded data.

“The coded data drives public policy,” says Toni Elhoms, CCS, CPC, CPMA, CRC, chief executive officer at Alpha Coding Experts, LLC in Orlando, FL. “It drives the SAMHSA funding. It’s all connected to the resources that are going to be provided to patients. It’s critical for physicians to code to the highest level of specificity.”

Jaci J. Kipreos, CPC, CPMA, CEO of Practice Integrity, LLC in San Diego, in agrees. “We need to raise awareness of the importance of the data,” she says. “Primary care physicians are truly the gatekeepers and can help identify the scope of this problem. The data they report is critical.”

Experts agree that when it comes to combatting the opioid, physicians need to shift their mindset and start focusing on data integrity. It starts by addressing the following common myths:

‘ICD-10-CM codes don’t affect my reimbursement.’

Not true, experts say. For example, most ICD-10-CM codes for opioid-related disorders are hierarchical condition category (HCC) codes, meaning they affect risk-adjusted payments for Medicare and many commercial payers.

In some cases, they could even yield higher-level evaluation and management codes due to higher-complexity medical decision-making, says Erica Remer, MD, CCDS, independent clinical documentation integrity consultant in Cleveland, Ohio. For example, a patient’s opioid-related disorder may affect what medications a physician prescribes, the dosage of those medications, or what additional tests they order.

“If you address the opioid use disorder in some way, you should document what you did and code the diagnosis,” says Remer.

Elhoms agrees, adding that physicians may be under-coding their E/M level without even realizing it. For example, if a physician ends up addressing social determinants of health, the E/M code could shift from level three to level four. Or when coding the E/M level based on time, helping a patient address their opioid use could even mean billing a prolonged services code, she adds.

“You might also be leaving money on the table by not billing for services you’re already providing,” says Elhoms. For example, a physician provides an E/M service, screens for opioid use disorder, and provides a brief 20-minute intervention after detecting the patient may be struggling with abuse or dependence. In this case, they may be able to bill CPT code 99408 as well as the E/M service with modifier -25, she adds.

There are also implications under Medicare’s Merit-based Incentive Payment System, particularly when patients with an opioid abuse disorder receive at least 180 days of continuous pharmacotherapy treatment, says Elhoms.

“ICD-10-CM codes are playing a bigger role as Medicare engages in direct contracting with primary care physicians,” says Elhoms. “The alternative payment models are all based on the data, and most of it is diagnosis code data. You can get custom rates from Medicare if you have solid data.”

‘I never know what opioid use disorder code to choose.’

Report one of the following ICD-10-CM codes for opioid-related disorders:

  • F11.1- (opioid abuse)
  • F11.2- (opioid dependence)
  • F11.9- (opioid use)

The tricky part is differentiating between abuse, dependence, and use—terminology that originated in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV, says Remer. says Remer. The current DSM-V instructs physicians to diagnose patients with an opioid use disorder when they determine at least two of the following symptoms have occurred within the last 12 months:

  • A lot of time spent using substances
  • Cravings for drugs or alcohol
  • Giving up activities to use drugs instead
  • Hazardous substance use
  • Legal problems due to drug abuse
  • Mental health problems due to substance abuse
  • Neglects major roles (in family, work, school) to use
  • Physical health problems related to use
  • Repeated unsuccessful attempts to quit or control use
  • Social and interpersonal problems related to drug use
  • Tolerance
  • Uses larger amounts of for longer than intended
  • Withdrawal symptoms when stopping use

When patients have two or more of the symptoms listed above, their opioid use disorder is considered mild. In ICD-10-CM, mild opioid disorder indexes to opioid abuse, explains Remer. However, when they have four or five symptoms, their opioid use disorder is moderate. When they have six or more symptoms, it’s considered severe. Both moderate and severe disorders index to opioid dependence, she adds.

ICD-10-CM code F11.9- is for patients who take opioids but don’t meet substance use disorder criteria. Code Z79.891 is for long-term use of opiate analgesic (as prescribed).

However, once physicians determine whether to report use, dependence, or abuse, they still should narrow down the codes even more, says Remer. For example, they may need to specify whether the patient is in withdrawal or whether they have intoxication or an opioid-induced psychotic disorder.

“Convenience is compelling, and doctors often use whatever code they can find,” says Remer. “However, this is problematic. If you don’t pick the right code, then trying to do epidemiologic research is very difficult.”

Remer suggests setting certain codes as ‘favorites’ in the EHR for easy access, but always making sure that the code accurately reflects the clinical picture as specifically as possible.

‘I don’t know how to bring up the topic.’

Incorporate questions about opioid use into your patient health questionnaire or use a separate opioid use assessment tool as part of your patient intake process, says Elhoms. Also leverage your medical assistant to gather as much social history data as possible, she adds.

‘I don’t have time to address opioid use disorders.’

The good news? You don’t necessarily need to. That’s because you can always make a warm referral to a mental health specialist, says Elhoms. “Reach out to your local public health department that may already have a list of mental health providers, support groups, and resources in your area,” she adds.

Another option is to provide and bill for psychiatric collaborative care (CPT codes 99492-99494). Under this model that pays approximately $154 for the first 70 minutes in the first initial month, physicians generate revenue when they co-manage patients with a psychiatrist or other behavioral health professional and provide ongoing care management and support.

‘I don’t want to label patients.’

Now that patients have access to their visit notes, Elhoms says some physicians worry that patients will be upset if they document a substance use disorder of any kind. That’s not the approach to take, she says. “It’s a mindset shift. Physicians need to avoid pretending like it’s not there. They need to pull it out and be more proactive about addressing it,” she adds.

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