When the provider documentation refers to use, abuse, and dependence of the same substance, how many codes should be used to identify the pattern of use?

In the context of provider documentation regarding use, abuse, and dependence of the same substance, only one code should be used to represent the overall pattern of substance use. This is because the coding guidelines allow for the use of a single code that encompasses the severity and nature of the substance-related condition. The documentation that combines these elements indicates a single overarching diagnosis rather than separate, distinct issues.

Using a single code streamlines the coding process without losing clarity about the patient's condition. There are specific guidelines that steer coders to capture the most comprehensive narrative in one code when dealing with substance use disorders. This practice not only simplifies the coding process but also prevents ambiguity in the patient's medical record, ensuring that all aspects of the issue are adequately represented within one diagnosis code.

The focus here is to accurately reflect the complexity of the patient's condition without unnecessary fragmentation into multiple codes.