If both use and dependence are documented for a psychoactive substance, which code is accurate?

In the scenario where both use and dependence on a psychoactive substance are documented, the most accurate coding practice is to select the dependence code only. This approach is consistent with the conventions of coding for substance-related disorders.

Dependence indicates a more severe level of dysfunction related to the substance, involving a physiological or psychological reliance on it, which may manifest through tolerance, withdrawal symptoms, and a compulsion to seek usage despite adverse consequences. The coding standards prioritize the most intense clinical presentation, which, in this case, is dependence.

Using a dependence code captures the severity and complexity of the individual's condition effectively. While use and abuse codes document lower levels of concern and risk associated with substance use, they do not fully represent the clinical picture when dependence is present. Selecting only the dependence code aligns with the guidelines that highlight the necessity to code for the most serious diagnosis or condition, ensuring accurate documentation in medical records and for billing purposes.