What is the recommended action if a provider documents substance use without signs of abuse or dependence?

Assigning a code for use is the recommended action when a provider documents substance use without evidence indicating abuse or dependence. This approach acknowledges that a patient may be using a substance without it impacting their life negatively. It is important to differentiate between substance use, which may be incidental or managed, and substance abuse or dependence, which implies a more serious level of concern requiring additional intervention and monitoring.

By using a code for use, healthcare providers can accurately reflect the patient’s current situation, allowing for appropriate care and tracking while avoiding the implications attached to codes for abuse or dependence, which would suggest a more severe issue. It's crucial for documentation and coding purposes to maintain this distinction to ensure that clinical assessments and treatment plans are correctly aligned with the patient’s actual condition.