AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 2; Ask the Editor
Recreational Marijuana Use
In the patient’s history and physical examination, the provider documented “recreational marijuana use.” Should recreational marijuana use be coded? ...
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Article Overview
This article addresses a common documentation question in medical coding: whether a note of recreational marijuana use is, by itself, enough to support reporting. It is aimed at coding professionals, auditors, and clinicians who document substance-related history, and it references official coding guidance for psychoactive substance use. The article focuses on when this type of documentation is and is not reportable, without going into broader clinical management.
Why This Topic Matters
Substance-use documentation appears frequently in histories and examinations, and coding teams need to distinguish incidental mention from reportable conditions. Understanding the applicable official guidance helps support consistent abstraction and reduce coding errors.
What You Will Learn
- How recreational marijuana use is addressed in coding guidance
- What type of documentation is relevant when considering substance-related reporting
- How official coding guidance applies to psychoactive substance use documentation
- When substance-use documentation may not be sufficient on its own
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Billers
- Compliance staff
- Clinicians who document histories and assessments
Codes Discussed
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