From time to time, we run into risk adjusted conditions that are “newly discovered” by coders without fully applying the diagnostic criteria. Those conditions are then suggested to providers, who may not be up on the requirements for the condition and who may report them incorrectly. As we’ve blogged countless times before, the goal of risk adjusted payments is to correctly fund the care of members with conditions that are costly today and for which future healthcare costs will be high. While leaving behind bonafide risk adjusted conditions can be financially deadly, reporting unsupported conditions brings about the same end sooner or later.

One set of conditions gaining popularity is the substance induced disorders. These are conditions that result from someone abusing or being dependent on a substance, such as alcohol, opioids, sleeping pills or illicit drugs. Believe it or not, caffeine is also included in this group, as is tobacco. The induced disorders include mood disorders like bipolar and depression, anxiety, sleep disorders, sexual dysfunction and a few more.

So, here’s where creativity runs amok: a patient has insomnia and the social history reveals the patient drinks coffee (example #1). Next thing you know, the coder is querying the provider to consider that the insomnia is resulting from the caffeine. Here’s another scenario (example #2): a 60-year old male with erectile dysfunction abuses alcohol. Here too, the coder may suggest linking the dysfunction as an induced disorder. At first glance, these can be intuitive conclusions, except that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5, outlines very specific criteria for linking substances to induced disorders, and it’s not as easy as you’d think.

For a complete understanding of substance induced d/o, we strongly recommend that you read the DSM-5, but below are the basics.

Proper linkage of an induced d/o requires that symptoms appear during or shortly after substance intoxication or withdrawal, terms that are specifically defined by the DSM-5. In our two situations above,

Example #1: Linking insomnia to caffeine requires that five or more symptoms begin shortly after recent consumption of more than 250 mg of caffeine. (This is the definition of caffeine intoxication, for you Starbucks fans.) In addition, the DSM states that symptoms cannot have preceded the onset of substance use; symptoms cannot persist for a substantial period (e.g. about one month) after cessation of intoxication; and there should be no evidence suggesting the existence of a non-substance induced disorder.

In plain language: if the person has a history of insomnia, or the insomnia continues after the caffeine intoxication has ended, or if there is another cause of the insomnia, it’s not an induced disorder.

Example #2: Linking sexual dysfunction to alcohol follows similar reasoning. First, the symptoms must appear during or shortly after intoxication or withdrawal after heavy or prolonged use. The person must exhibit at least two symptoms of withdrawal, such as pulse greater that 100 bpm, sweating, increased hand tremor, seizures or other specific issues. Or the person must exhibit one or more symptoms of intoxication, which include slurred speech, unsteady gait, stupor or other specified issues.

In addition, just as with our caffeine patient, symptoms must be clearly linked to the substance and not precede the onset of substance use, do not persist for a substantial period (e.g. about one month) after cessation of intoxication or withdrawal, and are not better explained by a non-substance induced disorder.

This means that if our 60-year-old male has a history of erectile dysfunction that preceded the intoxication or withdrawal, or if symptoms persist about a month after intoxication or withdrawal, and/or are better explained by other issues (such as age or prostate problems), it’s not appropriate to link it to the alcohol.

As you can see, the cavalier coding we’ve seen in some charts will probably not stand up to DSM-5 scrutiny. Obviously, induced disorders do exist, and providers need to be cognizant of the criteria so they can document an airtight case, linking the requisite symptoms to the behavior. Please feel free to request our FREE bulletin on substance-induced disorders.