EmailWithdrawal from poly drug dependence
Publication Date: December 2007
ICD 10 AM Edition: Fifth edition
Retired Date: 30/6/2013
Query Number: 2245
Scenario given at NCCH post implementation coding workshops (4th edition):
A 33 year old male was transferred from the District Hospital following an unrelated episode of care, where he had started to withdraw from his poly drug dependence. Upon admission the doctor noted an impression of significant symptoms of benzodiazepam, alcohol and opiate withdrawal (mainly benzodiazepam) and ordered withdrawal medication. Detoxification was initiated and the patient agreed to be discharged to a drug/alcohol rehabilitation unit.
NCCH answer presented at the seminar:
Principal diagnosis
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
Additional diagnoses
F11.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
Procedure
92009-00 [1872] Combined alcohol and drug detoxification
We would code the episode as:
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
F10.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F11.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
F13.2 Mental and behavioural disorders due to use of sedatives or hypnotics, dependence syndrome
F10.2 Mental and behavioural disorders due to use of opioids, dependence syndrome
F11.2 Mental and behavioural disorders due to use of alcohol, dependence syndrome
92009-00 [1872] Combined alcohol and drug detoxification
Could you please advise the correct codes to utilise for these scenarios.
Search detail:
Clinicial input:
October 25, 2005
To Whom It May Concern:
This letter is in response to a request regarding the coding of substance use disorders, specifically the assertion that an individual in substance withdrawal is necessarily dependent on or abusive of a substance. This assertion has no empirical evidence and is a misinterpretation of the DSM-IV-TR. Of greater concern, what may seem to be a trivial point, risks significantly biasing substance use statistics.
I would like to draw attention to the DSM definition of Substance Withdrawal, Abuse and Dependence.
Criteria for Substance Withdrawal (p.202):
A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.
B. The substance –specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
As per the Criteria, one clearly can withdraw from a substance without being Dependent or meeting criteria for Abuse of that substance. Criteria B, above, quite plainly states “clinically significant distress” which, does not necessarily beget the diagnosis of a substance use disorder.
With respect to dependence, while it is true that Withdrawal is one characteristic which may herald substance dependence it is neither sufficient nor necessary. The Criteria specifies that at least three of seven signs must be in place, of which Withdrawal is but one. The Criteria is as follows:
Criteria for Substance Dependence (p.197):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance
2. Withdrawal
3. The substance is often taken in larger amounts or over a longer period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
5. A great deal of time is spent in activities necessary to obtain the substance or recover from its effects
6. Important social, occupational or recreational activities are given up or reduced because of substance use
7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
In looking at substance abuse, there is also no mention of withdrawal as the focus is on maladaptive patterns of behaviour. Quite to the contrary, the DSM-IV-TR clearly states that abuse “does not include tolerance, withdrawal or a pattern of compulsive use” (p.198).
Criteria for Substance Abuse (p.199):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring within a 12-month period:
(1) Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
(2) Recurrent substance use in situations in which it is physically hazardous
(3) Recurrent substance-related legal problems
(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
It is imperative that there is an understanding that withdrawal, like intoxication, is merely a state caused by substances and is not synonymous with abuse or dependence. If this is in fact the way is to be recorded , than certainly all medical staff should be made aware of this. An equivalent, “more medical” example, would be the assumption that someone who presents with high cholesterol, necessarily has a diagnosis of heart disease, and therefore, heart disease should not be coded. This is simply not the case.
In closing, I am quite concerned that those clients receiving a code for substance withdrawal currently do not receive a code for abuse, or as is proposed, would not be coded for dependence. This has enormous potential to skew data and grossly underestimate the prevalence of substance use disorders. It reflects a misunderstanding of the nature of substance use disorders while ignoring the DSM-IV-TR criteria.
I would gladly further this discussion and look forward to your comments.
Regards,
Substance Use Research and Recovery Focused Program
A 33 year old male was transferred from the District Hospital following an unrelated episode of care, where he had started to withdraw from his poly drug dependence. Upon admission the doctor noted an impression of significant symptoms of benzodiazepam, alcohol and opiate withdrawal (mainly benzodiazepam) and ordered withdrawal medication. Detoxification was initiated and the patient agreed to be discharged to a drug/alcohol rehabilitation unit.
NCCH answer presented at the seminar:
Principal diagnosis
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
Additional diagnoses
F11.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F10.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
Procedure
92009-00 [1872] Combined alcohol and drug detoxification
We would code the episode as:
F13.3 Mental and behavioural disorders due to use of sedatives or hypnotics, withdrawal state
F10.3 Mental and behavioural disorders due to use of opioids, withdrawal state
F11.3 Mental and behavioural disorders due to use of alcohol, withdrawal state
F13.2 Mental and behavioural disorders due to use of sedatives or hypnotics, dependence syndrome
F10.2 Mental and behavioural disorders due to use of opioids, dependence syndrome
F11.2 Mental and behavioural disorders due to use of alcohol, dependence syndrome
92009-00 [1872] Combined alcohol and drug detoxification
Could you please advise the correct codes to utilise for these scenarios.
Search detail:
Clinicial input:
October 25, 2005
To Whom It May Concern:
This letter is in response to a request regarding the coding of substance use disorders, specifically the assertion that an individual in substance withdrawal is necessarily dependent on or abusive of a substance. This assertion has no empirical evidence and is a misinterpretation of the DSM-IV-TR. Of greater concern, what may seem to be a trivial point, risks significantly biasing substance use statistics.
I would like to draw attention to the DSM definition of Substance Withdrawal, Abuse and Dependence.
Criteria for Substance Withdrawal (p.202):
A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.
B. The substance –specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
As per the Criteria, one clearly can withdraw from a substance without being Dependent or meeting criteria for Abuse of that substance. Criteria B, above, quite plainly states “clinically significant distress” which, does not necessarily beget the diagnosis of a substance use disorder.
With respect to dependence, while it is true that Withdrawal is one characteristic which may herald substance dependence it is neither sufficient nor necessary. The Criteria specifies that at least three of seven signs must be in place, of which Withdrawal is but one. The Criteria is as follows:
Criteria for Substance Dependence (p.197):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance
2. Withdrawal
3. The substance is often taken in larger amounts or over a longer period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
5. A great deal of time is spent in activities necessary to obtain the substance or recover from its effects
6. Important social, occupational or recreational activities are given up or reduced because of substance use
7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
In looking at substance abuse, there is also no mention of withdrawal as the focus is on maladaptive patterns of behaviour. Quite to the contrary, the DSM-IV-TR clearly states that abuse “does not include tolerance, withdrawal or a pattern of compulsive use” (p.198).
Criteria for Substance Abuse (p.199):
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring within a 12-month period:
(1) Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
(2) Recurrent substance use in situations in which it is physically hazardous
(3) Recurrent substance-related legal problems
(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
It is imperative that there is an understanding that withdrawal, like intoxication, is merely a state caused by substances and is not synonymous with abuse or dependence. If this is in fact the way is to be recorded , than certainly all medical staff should be made aware of this. An equivalent, “more medical” example, would be the assumption that someone who presents with high cholesterol, necessarily has a diagnosis of heart disease, and therefore, heart disease should not be coded. This is simply not the case.
In closing, I am quite concerned that those clients receiving a code for substance withdrawal currently do not receive a code for abuse, or as is proposed, would not be coded for dependence. This has enormous potential to skew data and grossly underestimate the prevalence of substance use disorders. It reflects a misunderstanding of the nature of substance use disorders while ignoring the DSM-IV-TR criteria.
I would gladly further this discussion and look forward to your comments.
Regards,
Substance Use Research and Recovery Focused Program
Response
The VICC referred this query to the NCCH who provided the following advice:
"There is currently no directive preventing assignment of the .2 dependence syndrome code with the .3 withdrawal state code. The current NCCH advice is that it is unnecessary to assign both codes, as the dependence is inherent in the withdrawal state.
However ACS 0503 Drug, alcohol and tobacco use disorders will be amended in the Australian Coding Standards Sixth Edition and the above advice will be superseded as follows:
'While withdrawal rarely occurs in the absence of dependence, for consistent application of codes,
cases of withdrawal without mention of dependence syndrome should be assigned a code only for the withdrawal because dependence syndrome cannot be assumed.
Cases of dependence syndrome with withdrawal should be assigned both a code for the dependence syndrome and a code for the withdrawal syndrome because withdrawal is not always a feature of dependence syndrome. Dependence is syndromal (a cluster of phenomena) and withdrawal is only one non-essential criteria for dependence.' "
Given that there is some ambiguity in Coding Matters Vol 13 Number 3 which doesn't prevent coders from assigning two codes, the VICC advises that codes for both dependence and withdrawal should be assigned if documented.
"There is currently no directive preventing assignment of the .2 dependence syndrome code with the .3 withdrawal state code. The current NCCH advice is that it is unnecessary to assign both codes, as the dependence is inherent in the withdrawal state.
However ACS 0503 Drug, alcohol and tobacco use disorders will be amended in the Australian Coding Standards Sixth Edition and the above advice will be superseded as follows:
'While withdrawal rarely occurs in the absence of dependence, for consistent application of codes,
cases of withdrawal without mention of dependence syndrome should be assigned a code only for the withdrawal because dependence syndrome cannot be assumed.
Cases of dependence syndrome with withdrawal should be assigned both a code for the dependence syndrome and a code for the withdrawal syndrome because withdrawal is not always a feature of dependence syndrome. Dependence is syndromal (a cluster of phenomena) and withdrawal is only one non-essential criteria for dependence.' "
Given that there is some ambiguity in Coding Matters Vol 13 Number 3 which doesn't prevent coders from assigning two codes, the VICC advises that codes for both dependence and withdrawal should be assigned if documented.
