Combatting the Opioid Epidemic With Improved Documentation

On average, 115 Americans die every day from an opioid overdose. Since 1999, deaths from prescription opioids such as oxycodone, hydrocodone, and methadone have more than quadrupled.

Coded data is what drives these and many other statistics that help healthcare providers, researchers, and others understand the opioid epidemic and how to address it, says Jaci Kipreos, CPC, CPMA, CPC-H, CPC-I, president of Practice Integrity, LLC. “The easiest way to obtain global information is through claims and coded data,” she says. “That’s what codes have always been about—a way to capture information very easily. So, the emphasis becomes coding it correctly.”

Reporting opioid-related disorders can also help physicians boost payments under the Merit-based Incentive Payment System (MIPS). That’s because reporting these disorders, when appropriate, paints the picture for why costs may exceed the anticipated amount per beneficiary. For example, patients who are addicted to opioids may be more likely to require emergency room visits, drug rehab or hospitalizations. In 2018, the Centers for Medicare & Medicaid Services (CMS) will use cost data to determine payment adjustments. The cost category will be weighted at 10% of a clinician’s final score under MIPS for the 2018 performance period and 30% for the 2019 performance period and beyond.

Physicians who keep close tabs on patients for whom they prescribe opioid medication may also be able to boost payment under MIPS. They can do so by reporting the following quality measures for patients ages 18 and older who are prescribed opioids for longer than six weeks:

  1. Documentation of signed opioid treatment agreement
  2. Evaluation (using a brief validated instrument [e.g., Opioid Risk Tool or SOAPP-R]) or interview for risk of opioid misuse
  3. Opioid therapy follow-up evaluation at least every three months during opioid therapy

From a clinical standpoint, patients with an addiction to opioids may be good candidates for psychiatric collaborative care (CPT codes 99492-99494), a payable service for working with a psychiatric consultant and behavioral healthcare manager to co-manage patients with behavioral health disorders, says Kipreos. The physician bills Medicare monthly when the care team delivers services that meet or exceed a time threshold defined under the billing code. The physician then pays the behavioral healthcare manager and psychiatric consultant directly.

Four Tips to Document and Code Opioid-related Disorders

Kipreos offers these tips to promote accurate data capture:

1. Distinguish between use, abuse, and dependence.

In the absence of universal definitions for each of these terms, practices should take the time to agree on how they’ll use the verbiage consistently, says Kipreos. For example, physicians will document ‘use’ when patients take prescribed medication correctly, ‘dependence’ when patients can’t function properly without taking the medication, and ‘abuse’ when their use of the medication results in harm to themselves or others.

These definitions can apply to opioids as well as other drugs, such as tobacco and alcohol, says Kipreos. Ensuring that all physicians understand how to use these terms will support compliant and consistent billing, she adds.

2. Specify other complications.

This includes the following:

  • In remission
  • With intoxication (uncomplicated, intoxication delirium, or perceptual disturbance)
  • With opioid-induced mood disorder
  • With opioid-induced psychotic disorder (delusions or hallucinations)
  • With other opioid-induced disorder (sexual dysfunction or sleep disorder)
  • With withdrawal

“We have a lot of ways to describe these patients if that’s truly what’s happening,” says Kipreos.

3. Document other symptoms, co-morbidities.

Examples include respiratory failure, chronic obstructive pulmonary disease, heart disease, depression, and anxiety.

“It behooves providers to code for all of these additional co-morbidities so we can start to see trends in terms of what types of patients may be more susceptible to addiction,” says Kipreos. It’s about fostering population health management—that is, understanding why patients become addicted and what physicians can do prevent that from happening, she adds.

4. Validate coded data before submission.

Patients who use opioids can become dependent or abuse the drug at any time, says Kipreos. “Thus, the code may change every encounter as the patient either improves or worsens,” she says. Ensuring data integrity is paramount due to the sensitive nature of the problem, she adds.

To learn more about Kareo's support, training and solutions available for improved documentation and CMS incentive program reporting, contact us at

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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