Question:
Should recreational marijuana use be coded when documented by the patient’s provider?
Answer:
No, a code for the marijuana use is not assigned unless the provider documents an associated physical, mental, or behavioral disorder in accordance with ICD-10 Guideline I.C.5.b.3.
This guideline states “As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.”
– AHA Coding Clinic 2018, Second Quarter, page 11
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