Drug and Alcohol Use Coding Tip

When to Code Recreational Drug and Alcohol Use

With many states legalizing marijuana, “recreational marijuana use” has been appearing in physician documentation more frequently. Is this coded regularly in the same way that drug abuse and dependence is?

The answer is in the coding guidelines for Chapter 5 in Section II.5.b.3 “the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,F15.9-, F16.9-, F18.9-, F19.9-)… are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or  medical condition, and such a relationship is documented by the provider.” This guideline means that merely the documentation of drug/alcohol use alone is not enough to require coding. A good example of when alcohol use would be coded is if a patient has alcoholic cirrhosis and only alcohol use is documented. The alcohol use would be coded since there is an associated medical condition as described in the guideline. Coding clinic 2nd quarter 2018 pg 11 provides further guidance on recreational marijuana use. 

Coding Recreational Drug Use in Pregnancy

Coding drug use in a pregnant patient, however, requires different guidelines:

Per coding clinic 2nd quarter 2018 pgs 10-11 the drug use complicating pregnancy is coded for any drug use during pregnancy. Per the coding guidelines “It is the provider’s responsibility to state that the condition being treat is not affecting the pregnancy”. 

Drug use DISORDER is a different diagnosis and is coded differently:  

Per coding guideline Section II.5.b.1 “mild substance use disorders… are classified to the appropriate codes for substance abuse…and moderate or severe substance use disorders…. are classified to the appropriate codes for substance dependence.” Therefore, we have guidance that if mild drug use disorder is documented we code this as drug abuse, and if moderate or severe drug use disorder is documented we code this as drug dependence. The same applies to alcohol. If drug use disorder is documented without a severity, we cannot assume the severity and a query must be placed.  

Kendra Adams, RHIT 

Senior Consultant, Audit at UASI

With a strong background in health information technology and ICD-10 coding, Kendra Adams serves as a Senior Consultant in Audit at UASI. She contributes clear, practical coding tips rooted in real-world audit work to help coders improve accuracy, documentation quality, and compliant code assignment. 

Works Cited

American Hospital Association. (n.d.). AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS.
Available at https://www.codingclinicadvisor.com/ – the official portal for AHA Coding Clinic guidance and newsletters on ICD-10-CM/PCS updates and advice.

Centers for Medicare & Medicaid Services & National Center for Health Statistics. (2024). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025 (effective October 1, 2024).
Available at https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf