ICD-10 Guide

Substance Use Disorder

ICD-10 Coding for Substance Use Disorder(F10.20, F11.20)

PRIMARY SPECIALTYAddiction Medicine

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Substance Use Disorder?

Essential facts and insights about Substance Use Disorder

Key Clinical Considerations:

Craving for the substance, loss of control over use, and continued use despite negative consequences.
Urine drug screening, blood tests for substance levels, and psychological assessments.
Signs of withdrawal, changes in physical appearance, and behavioral changes.

Clinical Information

Clinical Criteria & Documentation Requirements

Patient history, substance use patterns, and impact on daily functioning.
ICD-10 terminology such as F10-F19 for specific substances.
Example: 'Patient presents with opioid use disorder, exhibiting tolerance and withdrawal symptoms.'

Coding Guidelines

Usage Guidelines & Examples

Follow guidelines for severity levels and specify substance type.
Common errors include using outdated codes or omitting severity indicators.

Code Exclusions

Important Exclusions

Conditions such as alcohol intoxication (F10.929) and substance-induced mood disorders.
Alternative codes for non-substance-related disorders.

Specialty Focus

Primary Specialty

Addiction Medicine

Specialty Applications

Adults and adolescents with substance use issues.
Addiction treatment centers, outpatient clinics, and hospitals.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed substance use history and assessment results.

Billing considerations?

Ensure accurate coding to reflect severity and treatment level.

Substance Use Disorder

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Substance Use Disorder

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?