Clinical Documentation Improvement Series #6. Substance Dependence and Associated Conditions
Unfortunately, in our society, substance dependence is rampant. There is alcohol dependence and illegal drug dependence. There is also dependence to opioid pain medications. The documentation of the disorders is critical to better describe the patient’s case and to seek adequate reimbursement for the utilized resources. Whenever there is substance dependence it is necessary to specify if there are intoxication, withdrawal or psychiatric conditions associated to it such as mood or anxiety disorders. For example, it is very different to treat an alcoholic who only needs counseling than to treat a case of delirium tremens in the ICU.
Marco A. Ramos MD, CCDS