New Opioid Addiction-Documentation Tip Sheet from AHIMA

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Opioid addiction has been declared a public health emergency in the United States. It is vital that organizations and providers provide high quality clinical documentation, to guarantee the data which drives research and education on this topic is based on the correct information. There are seven characteristics of high quality clinical documentation. If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation.

This tip sheet, available as a PDF download at the beginning of this post, has been developed to guide providers in learning the documentation elements that are needed when documenting opioid use, abuse, or dependency. In the tip sheet, each of the seven characteristics of high quality clinical documentation are listed in the first column. Under the example column are scenarios of when each of these characteristics is missing within the clinical documentation. The final column provides an example of poor documentation that is frequently seen in opioid documentation. Then there is an explanation of the missing clarity followed by what a high quality documentation statement would look like.

For more documentation-related content, visit the Journal of AHIMA blog “Documentation Detective.” This monthly blog discusses all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


  1. Please clarify your position in the row entitled “consistent” with the discussion on “conflicting documentation”. In that example, AHIMA is suggesting that documentation of use and abuse is inconsistent documentation that would require clarity. However, the Official Coding Guidelines direct that if both use and abuse are reported, that only abuse is reported. Is AHIMA suggesting that Opoids should be reported differently than other drug use/abuse?

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    • Hi Suzanne,

      No we are not suggesting that Opioids should be coded differently. This tip is focused on best practice documentation. A coding professional would probably not query in this example, but a CDI professionals would, because they would be focused on ensuring consistency in the documentation. This would then hopefully help prevent any potential concerns in the case.

      For example, let’s say a patient has “use” documented throughout a 5-day hospital stay and on one note, from a provider covering for the attending, “abuse” is documented. That could raise concerns about consistency. In CDI we always look for high quality clinical documentation so coding professionals can easily code out the case.

      Thank you,

      Tammy Combs RN, MSN, CCS, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer
      Director| HIM Practice Excellence, CDI/Nurse Planner

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  2. Good Afternoon –
    Although I applaud AHIMA on publishing documentation tips, I truly feel that we will still be missing the mark on this public health emergency. In my experience, physician documentation reflects their education of addiction, which we know their education was and is very low. Thus, getting physicians to document dependency with abuse is virtually nonexistent. In addition, the stigma of abuse, which is a behavior of addiction and dependency, is used inappropriately.
    Subconscious medical decision making at its finest is happening during this public health emergency.
    I feel it imperative that AHIMA step up to the plate and make it very clear that patients “abusing” their legal or illegal drugs are in more cases than not DEPENDENT. And that is the documentation that is currently missing and MUST be brought to the forefront for accurate development of public policy using patient health data.
    I am an advocate in FL, and have worked on many city, county and state and federal coalitions/task forces/etc. I am more than happy to share my years of experience with AHIMA in the interest of accurate documentation and data capture during this public health emergency.

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  3. Would AHIMA consider updating the document to inlcude the non-essential modifiers recognized in ICD-10-CM for alignment with the DSM-5? Coders and CDI professionals should expect to see healthcare providers using the language of the DSM-5 for the continuum of severity more than the terms for use, abuse and dependence.

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