a. Pain disorders related to psychological factors
Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41. Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain. See Section I.C.6. Pain
b. Mental and behavioral disorders due to psychoactive substance use
1) In Remission
Selection of codes for "in remission" for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider's clinical judgment. The appropriate codes for "in remission" are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting).
2) Psychoactive Substance Use, Abuse And Dependence
When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
- If both use and abuse are documented, assign only the code for abuse
- ICD-10-CM Official Guidelines for Coding and Reporting
- If both abuse and dependence are documented, assign only the code for dependence
- If use, abuse and dependence are all documented, assign only the code for dependence
- If both use and dependence are documented, assign only the code for dependence.
3) Psychoactive Substance Use
As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.