February 7, 2019
Correct documentation and coding of substance-related conditions allows providers to track patient behavior that can have a negative impact on the patient’s health. It also provides information to the researchers who are looking for better ways to care for patients with addictions.
When evaluating a patient with substance-related condition, providers need to document the following:
- Substance type
- Level of use (use, abuse or dependence)
- Accompanying conditions (withdrawal, anxiety or mood disorder, sexual dysfunction, etc.)
Learn more about documentation requirements associated with substance-related conditions.
For more information about documentation and coding of this and any other chronic or complex condition, email your Provider Clinical Consultant at providerclinicalconsulting@premera.com.