If both use and dependence are documented, what should be assigned?

When both use and dependence are documented, the correct coding practice is to assign only the code for dependence. This is because dependence is considered a more severe level of disorder than use or abuse, indicating that the individual has developed a physiological need for the substance.

In the context of coding, dependence encompasses the documented behavior and symptoms of the individual, thus reflecting the clinical picture more accurately. It therefore takes precedence over use in the coding hierarchy established by the ICD (International Classification of Diseases) guidelines.

If only the code for use were assigned, it would not accurately represent the patient's condition, as it downplays the severity of the situation. Similarly, focusing solely on abuse would be inappropriate because it fails to account for the dependency aspect that is present. Not assigning any codes would neglect to document the condition that the patient is facing, which is crucial for providing appropriate treatment and care. Altogether, assigning only the code for dependence maintains the integrity of the medical record and supports better clinical decision-making.