F19.939

HCC Category Mapping

What This Code Means

Stopping use of various psychoactive substances with withdrawal symptoms, but the specific type or severity is not documented.

Coding Tips

• •Use this code only when withdrawal is documented but specific symptoms are not clearly described
• •Clarify whether delirium or perceptual disturbances are present to assign a more specific code

Clinical Significance

Other psychoactive substance use, unspecified with withdrawal, unspecified indicates the patient is in substance withdrawal but the specific type or severity of withdrawal symptoms has not been documented. This is a documentation quality issue that should prompt a provider query, as the presence or absence of delirium or perceptual disturbances significantly changes the HCC mapping and RAF weight. Even in its unspecified form, this code still captures an important HCC for risk adjustment.

Documentation Requirements

• ✓Documentation that the patient is in active withdrawal from psychoactive substance(s)
• ✓Attempt to identify the specific substance(s) involved
• ✓Provider query to determine if delirium or perceptual disturbances are present
• ✓Description of withdrawal symptoms observed or reported
• ✓Monitoring and treatment plan documentation
• ✓Assessment of withdrawal severity using validated tools when possible

Commonly Confused Codes