Opioid Use Disorder Documentation Guide
Problematic pattern of opioid use causing significant impairment or distress, often requiring medication-assisted treatment.
ICD-10 Codes: F11.10, F11.11, F11.20, F11.21, F11.23, F11.90, F11.99
Common Symptoms
- Craving
- Tolerance
- Withdrawal symptoms
- Inability to control use
- Continued use despite harm
Key Documentation Elements
- Severity (mild, moderate, severe per DSM-5 criteria)
- MOUD type, dose, and induction protocol
- COWS score for withdrawal assessment
- Urine drug screen results
- Naloxone prescription and overdose prevention counseling
Documentation Challenges
- Documenting DSM-5 criteria and severity assessment
- Recording MOUD details (buprenorphine, methadone, naltrexone)
- Capturing COWS scoring for withdrawal management
- Tracking naloxone prescribing and overdose prevention education
Billing Considerations
- Use vs dependence coding (F11.1x vs F11.2x)
- MOUD prescribing documentation requirements
- Office-based opioid treatment billing codes
Frequently Asked Questions
How is opioid use disorder coded in ICD-10?
Mild OUD uses F11.10/F11.11, moderate-severe uses F11.20/F11.21. Remission uses F11.21. Scribeable selects the correct code based on your documented DSM-5 criteria and treatment status.
How does Scribeable document MOUD management?
Scribeable captures buprenorphine/methadone dosing, COWS scores, UDS results, naloxone prescribing, and counseling from your encounter, creating compliant medication-assisted treatment documentation.