If both abuse and dependence of the same substance are documented, what should be assigned?

When both abuse and dependence of the same substance are documented, the appropriate action is to assign only the code for dependence. This is because in the coding guidelines, substance dependence is considered a more severe condition than abuse and takes precedence clinically and in coding decisions.

By prioritizing the code for dependence, you ensure that the more intense and chronic nature of the patient’s substance use disorder is accurately represented in medical records and statistical reporting. Abuse may indicate problematic use, but dependence signifies a stronger physiological or psychological reliance on the substance, often requiring more intensive treatment and intervention.

The coding guidelines dictate that when both conditions are present, only the code for substance dependence should be documented, thereby enhancing the clarity and accuracy of the patient's clinical picture while complying with the established coding protocols.