Coding tips: Use, abuse, dependence — what’s the difference?

Definitions of psychoactive substances for documentation

Any psychoactive substance is considered a “drug” whether it is alcohol, cannabis, methamphetamine, opioids, or any number of other substances.

Basic definitions:

• Drug use – A pattern of using a psychoactive substance that is causing damage to a person’s health. The damage may be physical (for example getting hepatitis from IV drug use) or mental (for example depression from alcohol consumption)
• Drug abuse – simply put, it is desire to have the drug, when a person continues to use a “drug” even though they know it is having an adverse effect on their health or wellbeing even if their social life or financial stability may be falling apart.  They may put themselves or others in harm’s way (for example driving while intoxicated with children in the vehicle). They may be struggling with legal, social, or marital problems.
• Drug dependence – “A physiological need to have the drug.” This patient has built up a tolerance and needs more and more to get the same effects. They may go through withdrawal if they stop taking the drug. They have “lost control” over the substance.

Remember when documenting:

• Is it use, abuse or dependence?
• Name the drug being used
• Any associated complications?
• Lifestyle issues?
• Type of use, current remission, history of withdrawal or with current withdrawal
• Alcohol level if intoxicated or in withdrawal
• If the patient is pregnant note the LMP and weeks of gestation
• Any other contributing factors

For coding purposes:

• If the physician documents both use and abuse, Abuse will be coded.
• If the physic documents both abuse and dependence are documented, Dependence will be coded.
• If use and dependence are documented, Dependence will be coded.
• If use, abuse and dependence are documented, Dependence will be coded.
• If withdrawal is documented, Dependence will be coded.