Documenting to support quality – Nicotine dependence (alone) does not increase the patient’s portrayed level of illness in ICD-10. However, withdrawal (or active treatment and control) does support a higher level of illness. Withdrawal from nicotine dependence (or any drug) adds weight to the principal diagnosis.
Effective Coding Language: “Nicotine dependence with withdrawal symptoms controlled on Nicoderm.”
Establish dependence on nicotine, e.g.,
• Actively smoking and pack-years
• Number of cigarettes (or packs) per day
• The time to first cigarette of the day
Communicate manifestation of withdrawal symptoms (now, or in the past), e.g.,
• Irritability, soothed by a dose of nicotine
• Time between cigarettes before craving
Document active treatment of withdrawal symptoms
• Nebulized nicotine (vape)
Download the complete tip, Nicotine Dependence & Withdrawal.