Correct coding of Smoking - "Use" vs. "Dependence"

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Correct coding of Smoking - "Use" vs. "Dependence"

Postby JJones » Tue Aug 08, 2017 10:29 pm

Hello!

We are very interested in knowing the correct coding for these statements: 1. "Current every day smoker, .25 packs a day, cigarettes, times 10 years". This example was taken from the medical record history that was noted as reviewed by the provider. Is it acceptable to use information strictly from PFSH to apply a dx for smoking?

2. "Smoker" (nothing else noted). This example of "Smoker" is noted in the A&P with no other documentation anywhere else in the note.

In both cases, dependence is not noted by the provider. We are divided as a group on how to correctly code these. Would both cases be considered "use" as the provider does not state dependence, or is "dependence" correct as both state "smoker".


Thank you in advance for any help given.
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Re: Correct coding of Smoking - "Use" vs. "Dependence"

Postby admin » Tue Aug 15, 2017 2:13 pm

If the provider doesn’t call out nicotine dependence, and if there is no documentation with regard to the provider counseling the patient on overuse of tobacco or “nicotine dependence”, you are left with diagnosis code Z72.0, tobacco use, NOS.

We can only abstract, we cannot make that decision for the provider. He or she needs to paint a full picture in order to place a definitive diagnosis code.

Your question has been answered by Paul Spencer, CPC, COC
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