A Few Thoughts on Documentation and Coding of Methadone Maintenance

by Barry Libman, MS, RHIA, CDIP, CCS

As a coding professional and one responsible for education of coders and CDI, I care deeply about the accuracy and completeness of documentation. Our ultimate goal is clinical truth, not DRG optimization. Some clinical truths are easier to reflect than others.

A client recently approached us with a problem. The hospital coders and CDI were struggling with a circumstance where the medical record specifically documents ‘methadone maintenance’ but there is no indication in the record whether the methadone is intended to mitigate opiate dependence or is a form of long-term pain management.

Coding Methadone Maintenance to Mitigate Opiate Dependence
The ICD-10-CM Index to Diseases, under the main term maintenance and sub-term methadone, leads to code F11.20 (opiate dependence). These index entries were introduced in 2010, the same year that Coding Clinic (Q2 2010, p. 13) instructed that opioid dependence should be coded “to capture patients who are heroin addicts.” Unfortunately, there is no Coding Clinic advice for methadone maintenance cases without documentation of opioid dependence.

If the medical record documents that the patient was opiate dependent and now is on methadone maintenance, code F11.20 is correctly reported.

Faced with documentation of methadone maintenance and no other qualifying statements (such as history of opioid dependence or long-term pain management), one might be tempted to take advantage of guideline A.19 (if the physician documents a condition it should be coded) and report F11.20 which is a comorbid condition.

Coding Methadone Maintenance as a Form of Long-term Pain Management
Sometimes clinicians use the term ‘methadone maintenance’ to describe patients receiving methadone as a form of long-term pain management. This terminology may not be technically correct and provider education may be in order to allow for a more accurate characterization of the patient’s circumstance or clinical truth.

If the patient is receiving methadone for long-term pain management, code F11.20 does not seem correct because this range of codes is used to identify substance use and abuse disorders. Beyond the issues of data quality, reporting F11.20 on a patient prescribed methadone for pain management would be a disservice to the patient as it implies opiate dependence.

Long-term pain management by opiates can be described in a patient’s record using the code Z79.891 Long Term Current Use of Opiate Analgesic. Coding Clinic Q2 2018, pp. 11-12 appears to support this approach. (Coding Clinic disappointingly does not instruct the use of Z79.891, only that F11.20 should not be used to report a patient receiving a long term opiate as an analgesic.)

The ICD-10-CM Official Coding Guidelines note on p. 90 that Z79 codes (long-term drug therapy) “indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.”

This naturally raises the question of what code to use to report a patient that has been prescribed an opiate analgesic but is not described as “opiate-dependent.”

Coding Clinic Q2 2018, pp. 11-12
Q: Medical record documentation indicates the patient is taking opioids prescribed by their physician for treatment of chronic pain. Does Guideline I.C.5.b.3. mean that codes cannot be assigned for the opioid use unless there is documented an associated physical, mental, or behavioral disorder?
A: A code for the use of prescription opiates would not be reported because there is no associated physical, mental or behavioral disorder.

In summary, be cautious before assigning codes based solely on indexing. Remember that “a basic rule of coding is that further research is done if the title of the code suggested by the Index does not identify the condition correctly” as stated in Coding Clinic Q2 2017 p. 24 and Q1 2013 pp. 13-14. Hopefully official guidance will be published in the near future which will in turn make reflecting the clinical truth easier and less time consuming to debate, create queries and provide documentation education.

Barry’s Coding Clinic Update: in-depth commentary on selected coding advice and clarifications from recent issues of AHA Coding Clinic — all from a nationally-recognized authority on coding and reimbursement issues! Learn more here.

About the Author

Barry Libman, MS, RHIA, CCS
Barry is the founder of Libman Education, a leading provider of training for the health care workforce, as well as Barry Libman Inc., a company that provides coding, audit, and educational services to the HIM departments of healthcare institutions. Prior to forming these organizations, he held a number of positions in the health information management field, working for hospitals, insurers, consulting firms, and regulatory bodies. Barry is recognized for his in-depth knowledge of coding and reimbursement issues for acute care hospitals. An area of particular interest and expertise is Long Term Acute Care Hospital (LTACH) coding. Barry is often called upon to provide education and training on code updates and coding issues.

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