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Medical Billing and Coding Guide for Substance Abuse: All You Need to Know

Medical Billing and Coding for Substance Abuse December 1, 2021

In simple terms, substance abuse refers to the pattern of harmful use of any substance to change one’s mood.  Furthermore, the term “substances” can encompass not only alcohol and drugs ( legal or illegal) but also substances that do not technically qualify as drugs. On the other hand, “abuse” involves using a substance in a way that is not intended or recommended or when you consume too much of it. 

The substance abuse medical billing process is only one element of revenue cycle management, which begins with gathering accurate patient information. In this guide, we’ll guide you all you need to know about the Medical Billing and Coding Guide for Substance Abuse.

This table shows Outpatient SUD Services:

HCPCS or CPT® CodeModifierDescriptionServiceTaxonomy
H0001HDAlcohol and/or drug assessSubstance use disorder assessment, Pregnant and Parenting Women (PPW)261QR0405X
H0001HFAlcohol and/or drug assessSubstance use disorder assessment261QR0405X
H0004HF Alcohol and/or drug servicesIndividual therapy, without family present, per 15 minutes261QR0405X
H0038HFSelfhelp/peer svcSUD Peer Services 261QR0405X 
H0020HFAlcohol and/or drug servicesOpiate Substitution Treatment, methadone administration See the Opioid Treatment Programs (OTP) section of this guide for more information about Opioid Substitution Treatment. 261QM2800X
T1017HF Targeted case managementCase management, each 15 minutes251B00000X
96164HFHealth behavior intervention, group, face-to-face; initial 30 minutesGroup/ Face to face261QR0405X
96165HFHealth behavior intervention, group, face-to-face; each additional 15 minutesGroup/ Face to face261QR0405X
96167HFHealth behavior intervention, family (with the patient present), face-to-face; initial 30 minutesFamily w/ patient present/ face to face 261QR0405X
96168HFHealth behavior intervention, family (with the patient present), face-to-face; each additional 15 minutesFamily w/ patient present/ face to face 261QR0405X
96170 HFHealth behavior intervention, family (without the patient present), face-to-face; initial 30 minutesFamily without patient present, face to face261QR0405X
96171HFHealth behavior intervention, family (without the patient present), face-to-face; additional 15 minutesFamily without patient present, face to face261QR0405X

This table shows Residential SUD Services:

HCPCS or CPT® CodeModifierDescriptionServiceTaxonomy
H0010HAAlcohol and/or drug servicesYouth subacute withdrawal management3245S0500X
H0010 HFAlcohol and/or drug servicesAdult subacute withdrawal management324500000X
H0011HAAlcohol and/or drug servicesYouth acute withdrawal management3245S0500X
H0011HF Alcohol and/or drug servicesAdult acute withdrawal management324500000X
H0018HAAlcohol and/or drug servicesYouth recovery house3245S0500X
H0018HFAlcohol and/or drug servicesAdult recovery house324500000X
H0018HVAlcohol and/or drug servicesAdult intensive inpatient residential, w/o room and board, per diem324500000X
H0019HAAlcohol and/or drug servicesYouth intensive inpatient residential, w/o room and board, per diem3245S0500X
H0019HB Alcohol and/or drug services Residential treatment, Pregnant and Parenting Women (PPW) w/Children, w/o room, and board, per diem324500000X 
H0019HD Alcohol and/or drug servicesResidential treatment, Pregnant and Parenting Women (PPW) w/o Children, w/o room and board, per diem324500000X
H0019TGAlcohol and/or drug servicesResidential treatment, long term recovery324500000X
H2036HAA/D Tx program, per diemYouth room and board*3245S0500X 
H2036HFA/D Tx program, per diemAdult Room & Board*324500000X
H2036 HDA/D Tx program, per diemPPW room and board*324500000X

For more assistance on the billing guide, refer to this site.

Substance Abuse Diagnosis

Psychiatrists, psychologists, and licensed drug counselors are often involved in the evaluation process for diagnosing alcoholism, drug addiction, or other substance use disorders. Testing blood, urine, or other tests can assess drug use but not a diagnostic test for addiction. These tests can help monitor recovery as well as treatment.

Mental health professionals diagnose substance abuse using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

How to identify correct substance abuse ICD-10-CM codes?

ICD-10-CM uses the format F1x.xxx for substance use codes. In ICD-10-CM, the letter F indicates that the code belongs to Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders. Furthermore, the number 1 represents a mental or behavioral disorder due to the use of psychoactive substances. The first x, the next digit, indicates the problematic substance (see table below in Step 1). After the decimal point, all numbers indicate the severity and nature of the problem (see Table in Step 2 below). For example,  F10.121 refers to alcohol abuse with intoxication delirium. Not all specifiers are used for every substance (primarily perceptual disturbance), so users should refer to the complete ICD-10-CM code set.

Code1Mental and Behavioral Disorders due to… 
F10…use of alcohol
F11…use of opioids
F12…use of cannabis
F13…use of sedatives, hypnotics, anxiolytics
F14…use of cocaine
F15…use of other stimulants, including caffeine
F16…use of hallucinogens
F17…use of nicotine
F18…use of inhalants
F19…use of other psychoactive substances and multiple drug use
Specifiers for Substance CodingCode1
Abuse.1
Uncomplicated.10
With intoxication.12
…uncomplicated.120
…delirium.121
…with perceptual disturbance.122
…unspecified.129
With [insert substance] – induced mood disorder.14
With [insert substance] – induced psychotic disorder.15
…with delusions.150
…with hallucinations.151
…unspecified.159
With other [insert substance] – induced disorder.18
…anxiety disorder .180
…sleep disorder .182
…other [same-substance] – induced disorder .188
With unspecified [insert substance] – induced disorder.19
Dependence.22
Uncomplicated.20
In remission.21
With intoxication.22
…uncomplicated.220
…delirium.221
…with perceptual disturbance.222
…unspecified.229
With withdrawal.23
…uncomplicated.230
…delirium.231
…with perceptual disturbance.232
…unspecified.239
With [insert substance] – induced mood disorder.24
With [insert substance] – induced psychotic disorder.25
…with delusions.250
…with hallucinations.251
…unspecified.259
With [insert substance] – induced persisting amnestic disorder.26
With [insert substance] – induced persisting dementia.27
With other [insert substance] – induced disorders.28
…anxiety disorder.280
…sexual dysfunction.281
…sleep disorder.282
…other [same-substance] – induced disorder.288
With unspecified [insert substance] – induced disorder.29
Use, unspecified.9
With intoxication.92
…uncomplicated.920
…delirium.921
…with perceptual disturbance.922
…unspecified.929
With withdrawal.93
…uncomplicated.930
…delirium.931
…with perceptual disturbance.932
…unspecified.939
With [insert substance] – induced mood disorder.94
With [insert substance] – induced psychotic disorder.95
…with delusions.950
…with hallucinations.951
…sleep disorder .959
With [insert substance] – induced persisting amnestic disorder.96
With [insert substance] – induced persisting dementia.97
With other [inset substance] – induced disorders.98
…anxiety disorder.980
…sexual dysfunction.981
…sleep disorder.982
…other [same-substance] – induced disorder.988
With unspecified [insert substance] – induced disorder.99

For more information, you can visit the Centers for Disease Control and Prevention.

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