Revised guidelines for International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) were implemented on October 1, 2017, and apply to all services on and after that date.

One notable revision to the guidelines addresses coding of substance use, abuse, or dependence in remission. Affected guidelines are as follows, with new text underlined:

So, what do these changes mean in relation to reporting diagnoses? Codes for abuse in remission (codes end with .11) or dependence in remission (codes end with .21) are assigned when the physician or other qualified health care professional documents a substance use disorder is in remission or when instructed by the conventions of ICD-10-CM. Documentation of abuse or dependence or the status of the substance use disorder (mild, moderate, or severe) is necessary for code selection, as shown in the following example:

A 16-year-old patient with a history of cannabis abuse...

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