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ICD-10 Guide
ICD-10 CodesF13.988

F13.988

Billable

Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 F13.988 is a billable code used to indicate a diagnosis of sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder.

Key Diagnostic Point:

F13.988 refers to a condition characterized by the use of sedative, hypnotic, or anxiolytic substances that leads to unspecified disorders. This code encompasses a range of issues arising from the misuse of these substances, including addiction, withdrawal symptoms, and intoxication. Patients may present with various psychological and physical symptoms, including anxiety, depression, cognitive impairment, and behavioral changes. The diagnosis is often complicated by co-occurring mental health disorders, making it essential for healthcare providers to conduct thorough assessments. Treatment typically involves a combination of detoxification, counseling, and medication management to address both the substance use disorder and any underlying mental health issues. Accurate coding is crucial for appropriate treatment planning and reimbursement, as well as for tracking the prevalence of substance use disorders in the population.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of symptoms and disorders associated with sedative use
  • Potential for co-occurring mental health conditions
  • Need for comprehensive documentation of substance use history
  • Variability in treatment approaches based on individual patient needs

Audit Risk Factors

  • Inadequate documentation of substance use history
  • Failure to specify the type of sedative or hypnotic used
  • Lack of evidence for co-occurring disorders
  • Improper linkage between diagnosis and treatment provided

Specialty Focus

Medical Specialties

Psychiatry

Documentation Requirements

Detailed patient history, including substance use patterns, mental health evaluations, and treatment plans.

Common Clinical Scenarios

Patients presenting with anxiety disorders, insomnia, or substance use disorders requiring psychiatric intervention.

Billing Considerations

Consideration of dual diagnoses and the impact of sedative use on mental health treatment outcomes.

Addiction Medicine

Documentation Requirements

Comprehensive assessments, including DSM-5 criteria for substance use disorders and treatment progress notes.

Common Clinical Scenarios

Patients undergoing detoxification or rehabilitation for sedative use disorders.

Billing Considerations

Focus on the multidisciplinary approach to treatment, including behavioral therapies and pharmacotherapy.

Coding Guidelines

Inclusion Criteria

Use F13.988 When
  • According to ICD
  • 10 coding guidelines, F13
  • 988 should be used when the specific type of sedative, hypnotic, or anxiolytic is not documented, and when the disorder is not clearly defined
  • Coders should ensure that all relevant clinical information is captured to support the diagnosis

Exclusion Criteria

Do NOT use F13.988 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

H0031CPT Code

Mental health assessment

Clinical Scenario

Used when assessing a patient for sedative use disorder.

Documentation Requirements

Comprehensive assessment notes detailing substance use history and mental health status.

Specialty Considerations

Psychiatric evaluations should include substance use screening.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of substance use disorders, including F13.988. This specificity aids in better tracking of treatment outcomes and resource allocation for substance use treatment programs.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of substance use disorders, including F13.988. This specificity aids in better tracking of treatment outcomes and resource allocation for substance use treatment programs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of substance use disorders, including F13.988. This specificity aids in better tracking of treatment outcomes and resource allocation for substance use treatment programs.

Resources

Clinical References

  • •
    Substance Abuse and Mental Health Services Administration (SAMHSA)

Coding & Billing References

  • •
    Substance Abuse and Mental Health Services Administration (SAMHSA)

Frequently Asked Questions

What is the significance of using F13.988?

F13.988 is significant as it captures the complexities of sedative, hypnotic, or anxiolytic use disorders that do not fit neatly into other categories, allowing for appropriate treatment and resource allocation.