Q&A: Documentation for marijuana use and abuse

Why This Topic Matters

Substance-use documentation often appears in social history, but coding decisions depend on whether the record supports a reportable diagnosis. This topic matters because it helps coders understand when a note is likely sufficient for coding review and what broad ICD-10-CM category is involved.

Article Sections

1. Question

   Introduces the outpatient documentation scenario and asks how marijuana use documented in social history should be approached in coding terms.

2. Answer

   Explains the broader distinction between use and abuse, the need for supporting documentation, and the ICD-10-CM cannabis-related disorder category referenced by the article.

3. Editor’s note

   Provides source attribution and author background information.