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The American Journal of Managed Care February 2020
Care Coordination for Veterans With COPD: A Positive Deviance Study
Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
Expand Predeductible Coverage Without Increasing Premiums or Deductibles
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Melissa B. Gilkey, PhD; Lauren A. Cripps, MA; Rachel S. Gruver, MPH; Deidre V. Washington, PhD; and Alison A. Galbraith, MD, MPH
Co-payment Policies and Breast and Cervical Cancer Screening in Medicaid
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Medical Utilization Surrounding Initial Opioid-Related Diagnoses by Coding Method
Amber Watson, PharmD; David M. Simon, PhD; Meridith Blevins Peratikos, MS; and Elizabeth Ann Stringer, PhD

Medical Utilization Surrounding Initial Opioid-Related Diagnoses by Coding Method

Amber Watson, PharmD; David M. Simon, PhD; Meridith Blevins Peratikos, MS; and Elizabeth Ann Stringer, PhD
Medical utilization profiles of commercially insured members with opioid-related disorders differ depending on the code used to document the initial diagnosis in administrative claims.

Objectives: To identify methods for coding initial opioid-related disorder (ORD) diagnoses in administrative claims and determine whether coding methods correspond to acute medical utilization patterns.

Study Design: Retrospective analysis of Blue Health Intelligence commercial data.

Methods: We included members with 2 years of continuous coverage around the first appearance of an ORD diagnosis code (initial ORD) in medical or pharmacy claims with dates of service between October 2015 and March 2016. Initial ORD was identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) F11 codes or buprenorphine for medication-assisted treatment (BUP-MAT) with a duration of 3 or more days. Descriptive analyses were evaluated prediagnosis, in the month of diagnosis, and post diagnosis and included mean cost per member per month (PMPM); mean monthly percentage of members with at least 1 opioid agonist prescription (OAP), inpatient visit, or emergency department (ED) visit; and percentage of members with at least 1 ICD-10-CM Z79.891 code (long-term [current] use of opiate analgesic).

Results: A total of 6426 initial ORD diagnoses were identified by F11.20 (65.2%), F11.x (28.7%), and BUP-MAT (6.1%). PMPM costs for BUP-MAT ($2054) were lower than for F11.20 ($5053) and F11.x ($6597) in the diagnosis month. Mean monthly percentage of members with at least 1 OAP declined from pre– to post initial ORD diagnosis (F11.20, 52.5% to 50.0%; F11.x, 44.1% to 37.9%; BUP-MAT, 34.0% to 12.7%). Members with initial ORD coded as F11.x had the highest mean percentage with at least 1 inpatient or ED visit in the diagnosis month (30.9% and 26.8%, respectively) versus F11.20 (19.3% and 10.8%) and BUP-MAT (5.1% and 3.5%). Percentage of members with at least 1 Z79.891 code was higher post diagnosis than in the month of diagnosis (F11.20, 34.6% vs 25.7%; F11.x, 16.5% vs 8.1%; BUP-MAT, 19.5% vs 8.1%).

Conclusions: Medical utilization patterns of members with ORD differ by the coding method used to document their initial diagnosis in administrative claims.

Am J Manag Care. 2020;26(2):e64-e68.
Takeaway Points
  • Payers are incentivized to facilitate population health interventions for opioid-related disorders (ORDs), requiring an understanding of ORD coding methods.
  • In this analysis, 65% of commercial members who received their first ORD diagnosis were coded with opioid dependence. Contrary to the recommended course of care for opioid dependence, defined as moderate or severe opioid use disorder, 50% continued to receive opioid agonist prescriptions. We also observed that 35% received at least 1 diagnosis code indicating long-term opioid agonist treatment for pain.
  • This suggests that long-term opioid therapy may be documented as opioid dependence in claims, which could mischaracterize these members as having ORD and affect their care; thus, better coding guidance is needed.
Insured persons (members) with opioid use disorder (OUD), opioid abuse, opioid misuse, or opioid dependence—hereafter referred to as opioid-related disorder (ORD)—exhibit elevated payer costs and healthcare utilization compared with members without ORD.1-4 This may incentivize payers to facilitate population health interventions, especially for members with untreated or newly diagnosed ORD, which necessitates understanding of ORD coding and accurate documentation of ORD when submitting claims for reimbursement.5

However, ORD coding is complicated by discrepancies among coding guidelines and interpretation of code descriptions.6 This is especially true for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code F11.20 (opioid dependence, uncomplicated).7 Coding guidelines for a diagnosis of opioid dependence (Table 18-11) are consistent with the World Health Organization definition of dependence, and these guidelines reserve F11.20 for moderate/severe OUD or dependence on prescription or illicit opioids for nonmedical use.8-11 However, contrary to this definition, F11.20 is often applied to members who have developed physical dependence on opioid agonist prescriptions (OAPs) due to long-term prescription therapy, even when used as directed.12 Thus, members on appropriate long-term OAPs can be mischaracterized as having ORD upon review of claims data, and this could affect the care they receive post diagnosis.13 In the absence of known opioid misuse or abuse, ICD-10-CM code Z79.891 (long-term [current] use of opiate analgesic) is recommended for indicating long-term OAP for pain treatment (Table 18-11) and offers a method for distinguishing this member population from those with ORD.10

This analysis describes how initial ORD diagnoses were coded in 1 administrative database and presents the following measures for each coding method: mean dollars spent per member per month (PMPM); mean percentage of members with at least 1 OAP, all-cause inpatient visit, or all-cause emergency department (ED) visit each month; and percentage of members with at least 1 ICD-10-CM Z79.891 diagnosis in a specified time period. Results highlight that medical utilization profiles differ by coding method for initial ORD diagnoses and suggest that better guidance is needed regarding coding practices for long-term OAP.


This was a retrospective study of administrative claims for members with commercial health coverage from Blue Health Intelligence.14 The data set contains deidentified eligibility information, pharmacy claims, and medical claims for more than 8.7 million members across all US states and territories.

Data between January 1, 2011, and March 31, 2017, were reviewed. Members were included in the analysis if they had at least 2 years of continuous health coverage centered around an initial ORD code that occurred in the assessment period (October 1, 2015, to March 31, 2016). No age restrictions were applied. Members with any previous ORD code before October 1, 2015 (prior to ICD-10-CM mandated implementation), were excluded. Members were identified for exclusion using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for opioid abuse and dependence (304.0x, 304.7x, 305.5x) or by a prescription claim before October 1, 2015, for any buprenorphine for medication-assisted treatment (BUP-MAT) product with a duration of 3 or more days.15 ORD was identified in the assessment period by ICD-10-CM F11 codes for opioid abuse, dependence, or use, or by a prescription claim for any BUP-MAT product with a duration of 3 or more days.7 The code F11.20 (opioid dependence, uncomplicated) was examined separately from other F11.x codes to understand the impact of F11.20 code application to both physical dependence and OUD on medical utilization or cost differences. A BUP-MAT duration of 3 or more days excluded members receiving a short course of buprenorphine for acute opioid withdrawal, which may not equate to an ORD diagnosis.16 Because the intent was to capture the first documentation of an active ORD diagnosis, remission codes (F11.11 and F11.21) were excluded from the assessment period. Any F11 diagnosis associated with the CMS Place of Service (POS) code 81 (independent laboratory) was excluded to avoid capturing laboratory services as a source of medical diagnosis.17 For members with both F11.20 and F11.x codes on the same date, ties were broken per ICD-10-CM coding guidelines (Table 18-11): BUP-MAT > F11.20 > F11.x.

Using the first date of initial ORD diagnosis in medical and pharmacy claims (ie, ORD diagnosis with no prior history of ORD), the following descriptive analyses were evaluated prediagnosis (1 to 365 days before diagnosis), month of diagnosis (0 to 30 days after diagnosis), and post diagnosis (31 to 365 days after diagnosis): mean cost PMPM and mean percentage of members with at least 1 OAP, inpatient visit, or ED visit in each month averaged across the specified time periods. The percentage of members receiving at least 1 ICD-10-CM code for long-term opioid use (Z79.891) in the month of initial ORD diagnosis and post diagnosis was also evaluated; it was not evaluated prediagnosis because this period overlaps with use of ICD-9-CM, and the only comparable ICD-9-CM code (V58.69; long-term [current] use of other medications) is not specific to opioids.15 Cost refers to the amount paid by the insurer. Inpatient and ED visits were assumed as all-cause and not specific to opioid-related incidents. ED visits were identified by POS code 23 (emergency room—hospital) or by the presence of both POS code 21 (inpatient hospital) and an ED revenue code (0450, 0451, 0452, 0453, 0454, 0455, 0457, 0458, or 0459). Inpatient visits were identified by POS code 21 in the absence of an ED revenue code.

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