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The American Journal of Managed Care February 2020
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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.

A total of 6426 initial ORD diagnoses were identified. Of these, 120 members were coded for ORD by both F11.20 and F11.x on the same date and were then assigned F11.20 as the primary diagnosis per coding guidelines (Table 18-11). Initial ORD diagnoses were divided into 3 diagnosis types: F11.20 (65.2%), F11.x (28.7%), and BUP-MAT of 3 or more days (6.1%).

Mean PMPM costs prediagnosis and during the month of diagnosis for F11.20 ($1656 and $5053, respectively) and F11.x ($1812 and $6597) were more than twice those for BUP-MAT ($756 and $2054) (Table 2). Post diagnosis, mean PMPM costs dropped from the month of diagnosis but remained elevated compared with prediagnosis for all 3 diagnosis types: F11.20 ($1803), F11.x ($2069), and BUP-MAT ($1148).

The mean percentage of members with at least 1 OAP each month prediagnosis was highest among F11.20 (52.5%), followed by F11.x (44.1%) and BUP-MAT (34.0%) (Table 2). The difference across all time periods ranged from 8% to 12% higher for F11.20 compared with F11.x. Incident diagnoses identified by a sustained BUP-MAT prescription had a sharp drop in mean percentage of members with an OAP each month from prediagnosis (34.0%) to month of diagnosis (9.1%) and post diagnosis (12.7%).

Members with F11.x as an incident diagnosis had the highest percentage with at least 1 inpatient visit during the month of diagnosis (30.9%) compared with F11.20 (19.3%) and BUP-MAT (5.1%) (Table 2). The mean percentage of members with at least 1 inpatient visit each month decreased post diagnosis: F11.20 (3.8%), F11.x (4.7%), and BUP-MAT (2.4%).

Similar to PMPM costs, the mean percentage of members with at least 1 ED visit each month was higher for F11.20 and F11.x compared with BUP-MAT across all time periods (Table 2). During the month of diagnosis, more members with diagnosis type F11.x (26.8%) visited the ED at least once compared with F11.20 (10.8%) and BUP-MAT (3.5%).

The percentage of members with at least 1 Z79.891 code during the month of ORD diagnosis was highest among F11.20 (25.7%) compared with F11.x (8.1%) and BUP-MAT (8.1%) (Table 2). Compared with the month of diagnosis, a higher percentage of members across all diagnosis types received at least 1 Z79.891 code in the 11-month postdiagnosis period: F11.20 (34.6%), F11.x (16.5%), and BUP-MAT (19.5%).


This analysis characterizes methods for coding incident ORD diagnoses in administrative data using prescription claims for any BUP-MAT product with 3 or more days’ duration and any ICD-10-CM F11 code for opioid abuse, dependence, or use. Future analyses could examine opioid overdose codes as an ORD indicator. Medical utilization profiles and payer costs for members receiving incident Z79.891 (long-term [current] use of opiate analgesic) versus F11.20 (opioid dependence, uncomplicated) codes could also be evaluated.

The majority (65.2%) of members in this analysis had an initial ORD diagnosis coded in administrative claims by application of F11.20 (opioid dependence, uncomplicated). We evaluated F11.20 separately from F11.x to determine if its application to members prescribed OAP therapy and to members otherwise dependent on prescription or illicit opioids for nonmedical use contributes to differences in acute medical utilization compared with members with other ORDs. If the F11.20 population in this analysis exclusively represented those with moderate or severe OUD (Table 18-11), we would expect to observe higher acute medical utilization and expenditure than members diagnosed with mild OUD (F11.1x) or abuse (F11.9x).1However, mean PMPM costs and inpatient and ED utilization for the F11.20 group were lower than that of the F11.x population across all time periods, even in the month of diagnosis, during which values peaked (Table 2). Conversely, the mean percentage of members with at least 1 OAP each month and with coded long-term use of OAP (Z79.891) was higher in the F11.20 group compared with F11.x. These results suggest that at least a portion of the F11.20 population is representative of those stable on long-term OAP without a true OUD indication and underscore the need for better education and guidance for appropriate application of F11.20 versus Z79.891. Additionally, there exists a subset of long-term OAP users who develop “complex persistent dependence,” a diagnostic gray area between physiologic dependence and OUD, and thus may be coded with F11.20 while still continuing to receive OAPs for pain treatment.18 Given the high rate of OAP each month post diagnosis in both the F11.20 and F11.x groups, it may be worthwhile to investigate provider specialties associated with specific diagnoses and whether the F11 codes and OAPs are received from the same practitioner.

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