Q&A: Bridging the gap between DSM-5, ICD-10 for substance-related disorders

Q: Why is it necessary for coders, CDI professionals, and providers to align documentation and coding for substance-related disorders when applying both the DSM-5 and ICD-10? How does this impact risk adjustment and HCC capture?

A: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recognizes substance-related disorders resulting from the use of 10 separate classes of drugs that includes alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, stimulants, tobacco, other or unknown substances, and sedatives, hypnotics, and anxiolytics. From a coding perspective, substance use disorders map to a corresponding ICD-10-CM code based on the type of substance use.

Terminology used in the DSM-5 does not always align nicely with ICD-10 coding descriptions, which leads to a common documentation gap that makes proper coding difficult. This is why there needs to be a crosswalk between the DSM-5 and the ICD-10-CM. The DSM-5 uses a single term, like substance use disorder, and then classifies the disorder by severity (e.g. mild, moderate, or severe). On the other hand, the ICD-10 separates codes into abuse and dependence. Simply put, mild use disorder equals abuse, and moderate or severe use disorder equals dependence. It ultimately comes down to semantics.

Providers often document based on DSM-5 terminology without realizing the coding system still uses the older abuse and dependence language. A template that assists providers in selecting the appropriate substance use disorder based on the number of symptoms present can help guide code selection later down the road.

For example, if a patient meets criteria for a substance use disorder with six or more symptoms present, the template can populate the severity, which in this case is severe, and suggest the appropriate corresponding ICD-10 diagnosis. Reviewing real world scenarios to build coding and documentation habits that support both accuracy and risk adjustment can also help ensure that the patient's clinical picture is fully represented in the chart and risk model.

Capturing substance use disorder diagnoses accurately has a significant impact on risk adjustment, especially when the severity meets moderate or severe criteria that maps to a dependence code in ICD-10. It's worth noting that the substance use disease group has been revised to include Hierarchical Condition Category (HCC) 135-139 in the current CMS model.

Additionally, substance use disorders are considered to be conditions that likely persist and are not considered to be curable as there is a high rate of relapse in patients with these disorders. Looking at the ICD-10-CM, there is not a code for history of substance use disorder. Rather, patients who no longer meet the DSM-5 criteria for substance use disorders except for craving are considered to be in remission and should be reported accordingly using a substance use disorder in remission code, which does adjust the risk level in the current HCC model.

Patients with substance use disorders often have highly complex healthcare needs with coexisting chronic conditions such as diabetes, chronic kidney disease, congestive heart failure, and COPD. For those with long standing alcohol use disorder, coders and CDI professionals should particularly watch for symptoms like withdrawal, intoxication, and chronic conditions such as alcoholic cirrhosis that may be present.

Complications, especially those coded with modifiers such as “with withdrawal” or “with psychotic disorder,” carry significant HCC weights. Older adult patients battling a substance use disorder also suffer from mood or mental health disorders like major depressive disorder. These often coexist and need to be documented and coded separately. In capturing these associated conditions, a fuller clinical picture can be painted, supporting medical necessity and helping with appropriate risk adjustment. If a patient is experiencing withdrawal symptoms or an alcohol-induced mood disorder, for example, that will change both the clinical management and the coding and documentation of the condition.

While outpatient providers do the lion's share of the work in managing those chronic conditions, inpatient teams also play a role in identifying the conditions so that they can be managed in the outpatient setting. If a patient is admitted for complications like overdose, delirium, or withdrawal, it is important to confirm whether a substance use disorder is also present. Providers will certainly treat the acute issue but may not fully document the underlying substance use disorder.

Clarifying and appropriately capturing the diagnosis during the inpatient stay ensures that the diagnosis is on the radar for outpatient teams. It supports continuity of care and contributes to both HCC capture and care coordination. Substance use disorders are considered to be conditions that likely persist, meaning that if they are present during the inpatient stay, it will need to be reevaluated in the outpatient stay because it often remains relevant to the outpatient setting.

Editor’s note: This Q&A originally appeared in JustCoding. Taylor Wiggins, DNP, RN, a CDI leader with over a decade of nursing experience and background in risk adjustment and outpatient documentation strategy, answered this question on the July 17, 2025, episode of The ACDIS Podcast.