More than 10 million people abuse opioids each year, according to the National Center for Drug Abuse Statistics. Overdose deaths involving opioids increased by 519.38% from 1999 to 2019. These alarming statistics and others like them are why the US Department of Health and Human Services (HHS) has officially declared the opioid crisis a public health emergency in 2017.
Most recently, HHS announced it would 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 Meanwhile, the Centers for Disease Control and Prevention (CDC) released updated draft guidance on when to start opioid prescribing, selection and dosage, duration and follow-up, and risk assessment. and damage resolution.
It’s all part of an effort to support doctors in their quest to help patients struggling with opioid use disorder. At the heart of these efforts? Encoded data.
“Coded data drives public policy,” says Toni Elhoms, CCS, CPC, CPMA, CRC, CEO of Alpha Coding Experts, LLC in Orlando, Florida. “This motivates the funding of SAMHSA. Everything is related to the resources that will be provided to patients. It is essential that physicians code at the highest level of specificity.
Jaci J. Kipreos, CPC, CPMA, CEO of Practice Integrity, LLC in San Diego, agrees. “We need to raise awareness of the importance of data,” she says. “Primary care physicians are really the gatekeepers and can help identify the extent of this problem. The data they report is essential.
Experts agree that when it comes to fighting opioids, doctors need to change their mindset and start focusing on data integrity. It begins by addressing the following common myths:
“ICD-10-CM codes do not affect my refund.”
That’s not true, say the experts. 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 payers. commercial.
In some cases, they might even produce higher-level assessment and management codes due to more complex medical decision-making, says Erica Remer, MD, CCDS, independent clinical documentation integrity consultant in Cleveland, Ohio. For example, a patient’s opioid disorder may affect the medications a doctor prescribes, the dosage of those medications, or the additional tests they order.
“If you’re treating opioid use disorder in any way, you need to document what you did and code the diagnosis,” says Remer.
Elhoms agrees, adding that doctors can undercode their E/M level without even realizing it. For example, if a physician ends up dealing with the social determinants of health, the E/M code could change from level three to level four. Or when coding the E/M level against time, helping a patient manage their opioid use could even mean billing an extended service code, she adds.
“You could also be leaving money on the table by not charging for services you already provide,” says Elhoms. For example, a physician provides E/M service, screens for opioid use disorder, and provides a brief 20-minute intervention after detecting that the patient may be struggling with abuse or addiction. In this case, they may be able to charge CPT code 99408 as well as E/M service with the -25 modifier, she adds.
There are also implications under Medicare’s merit-based incentive payment system, particularly when patients with opioid abuse disorder receive at least 180 days of continuous drug therapy, explains Elhoms.
“ICD-10-CM codes play a bigger role as Medicare enters into direct contracts with primary care physicians,” Elhoms says. “Alternative payment models are all data-driven, and most are diagnostic code data. You can get personalized rates from Medicare if you have solid data.
“I never know which opioid use disorder code to pick.”
Report one of the following ICD-10-CM codes for opioid-related disorders:
- F11.1- (opioid abuse)
- F11.2- (opiate dependence)
- F11.9- (opioid use)
The tricky part is differentiating between abuse, addiction and consumption — a terminology that originated in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV, Remer says. Remer said. The current DSM-V instructs physicians to diagnose patients with opioid use disorder when they determine that at least two of the following symptoms have occurred within the past 12 months:
- A lot of time spent using substances
- craving for drugs or alcohol
- Giving up activities to use drugs instead
- Use of hazardous substances
- Legal problems due to drug addiction
- Mental health issues due to substance abuse
- Neglects primary roles (in family, work, school) to use
- Substance-related physical health problems
- Repeated unsuccessful attempts to stop or control use
- Social and interpersonal problems related to drug use
- Uses larger amounts of for longer than intended
- Withdrawal symptoms when discontinuing use
When patients have two or more of the symptoms listed above, their opioid use disorder is considered mild. In ICD-10-CM, benign opioid opioid disorder index abuse, explains Remer. However, when they have four or five symptoms, their opioid use disorder is moderate. When they have six or more symptoms, they are considered strict. Moderate and severe disorders are indexed to opioids addictionShe adds.
ICD-10-CM code F11.9 is for patients who are taking opioids but do not meet the criteria for substance use disorder. Z79.891 is for long-term use of opioid pain relievers (as prescribed).
However, once doctors have determined whether to report use, addiction, or abuse, they still need to refine the codes further, Remer says. For example, they may need to specify whether the patient is in withdrawal or suffering from intoxication or an opioid-induced psychotic disorder.
“The convenience is compelling, and doctors often use whatever code they can find,” says Remer. “But it’s problematic. If you don’t choose the right code, then trying to do epidemiological research is very difficult.
Remer suggests setting certain codes as “favorites” in the EHR for easy access, but always ensuring that the code accurately reflects the clinical picture as accurately as possible.
“I don’t know how to broach the subject.”
Integrate questions about opioid use into your patient health questionnaire or use a separate opioid use assessment tool as part of your patient intake process, Elhoms says. Leverage your Physician Assistant, too, to collect as much social history data as possible, she adds.
“I don’t have time to talk about opioid use disorders.”
The good news? You don’t necessarily need it. That’s because you can always make a warm referral to a mental health specialist, Elhoms says. “Contact your local public health department who 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 collaborative psychiatric care (CPT codes 99492-99494). Under this model, which pays approximately $154 for the first 70 minutes of the initial first month, physicians generate revenue when they co-manage patients with a psychiatrist or other behavioral health professional and provide management and counseling. ongoing care support.
“I don’t want to label patients.”
Now that patients have access to their visit notes, Elhoms says some doctors worry that patients will be upset if they document a substance use disorder of any kind. This is not the approach to take, she said. “It’s a change of mentality. Physicians should avoid pretending that there is none. They need to take it down and be more proactive about addressing it,” she adds.