Addiction: AKA Substance Abuse Disorder

Substance abuse is a pervasive issue with profound implications for hospitals. It’s been estimated that up to 25percent of hospitalized patients have a substance abuse disorder. And up to 44percent of these abuse some substance during hospitalization. Substance abuse is a frequently contributor to readmissions and chronic diseases. The complexity of substance use disorders requires a nuanced understanding of diagnostic categories, and accurate coding.

Let’s start with definitions. The definitive source for behavioral disorders is the Diagnostic and Statistical Manual, or DSM. “Addiction” isn’t used as a specific diagnosis in the DSM-5 but is generally as understood as severe substance use disorder. The DSM-5 combines previous categories of “substance abuse” and “substance dependence” into Substance Use Disorder, with severity levels ranging from mild to severe. These severity levels are based on the number of diagnostic criteria met within a 12-month period. There are 11 criteria grouped into four categories covering impaired control, social impairment, risky use, and pharmacological criteria such as tolerance and withdrawal.

It’s not a simple diagnosis.

Additionally, the International Classification of Diseases (ICD-10) also provides criteria for diagnosing these disorders. Some of the categories include recreational use, intoxication, three classes of substance abuse disorder, and substance-induced disorders such as psychosis, mood disorders, and cognitive impairment. Each of these have their own definitions.

Acutely intoxicated patients may present for myriad reasons including detox.  The underlying cause of the acute intoxication may independently have healthcare implications. In reality, long-term substance abuse may have adverse healthcare consequences not well-described by current definitions or terminology.

It is possible- but unlikely- that during an acute hospital confinement providers will be able to obtain and comprehensively document robust history encompassing all of the diagnostic components to convert acute intoxication diagnoses to substance abuse disorder. After all, DSM-5 gives providers 12 months to accrue all components. Of course, a provider could rely on previous diagnoses in the historical record.  But, again, as I remind providers if you put it over your signature, you own that diagnosis regardless of its ultimate provenance or veracity.

By now you’re wondering where I’m going. Well, where I’m going is that definitions matter. The record must reflect all the criteria supporting the diagnosis. A shift from acute intoxication to substance abuse disorder may yield a modest improvement in severity of illness, risk of mortality, or reimbursement but those changes are only helpful if they don’t result in a denial. As I’ve noted previously, every diagnosis must be either paid or denied by the payer. Either of those alternatives results in additional cost to the payer. Also, managing the denial obligately erodes margin for providers- regardless of the outcome of the appeal.

There are also patient concerns. Under-diagnosing a patient may deprive the patient of necessary services leading to drug-related consequences. This may expose providers to liability. Over-diagnosing a patient may limit post-acute care options or insurability.

What these concerns mean is that providers, coding, and CDI programs must work together to assure that every step in the diagnosis-to-documentation- to-coding continuum is scrupulously accurate. Other than cancer, there’s probably no higher risk diagnosis.