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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.
In contrast to either F11 group, members whose incident ORD diagnoses were coded via receipt of a BUP-MAT product with a duration of 3 or more days had lower mean PMPM costs and lower mean percentages of OAP, inpatient visits, or ED visits each month in the prediagnosis, month of diagnosis, and postdiagnosis periods (Table 2), consistent with previous analyses.19-21 This implies that earlier MAT intervention for ORD may prevent costly escalations in healthcare. Comorbid conditions, drivers, or patterns contributing to inpatient or ED utilization were not explored, and further research is warranted.

The mean percentage of members with at least 1 OAP in the BUP-MAT group decreased from prediagnosis (34.0%) to post diagnosis (12.7%), a sharper decline in OAP than in either F11 group. The mean percentage of members in the BUP-MAT group with at least 1 coded diagnosis of long-term OAP (Z79.891) increased from the month of diagnosis (8.1%) compared with the 11 months post diagnosis (19.5%). Implications for this finding could be 2-fold: (1) Long-term BUP-MAT is being coded with the same Z79.891 code or (2) practitioners are increasingly utilizing buprenorphine sublingual formulations to treat pain.22 Coding guidelines indicate that maintenance medications for drug dependence should not be coded as Z79.891 (Table 18-11). If BUP-MAT is being coded as Z79.891, this further reiterates the need for better education around appropriate code utilization.


This analysis relies on the accuracy of claims data in which ORD is likely underreported.23 Results for this commercially insured population may not be generalizable to other insured or uninsured populations. Claims history was limited to dates of service on or after January 1, 2011, preventing full visibility into prior ORD diagnosis codes that members may have received. Measures were not compared against medical records to verify accuracy of diagnoses.


The ICD-10-CM F11.20 code represents a large percentage of initial ORD diagnoses. Members coded with incident F11.20 exhibited lower mean PMPM costs and fewer inpatient or ED visits compared with the F11.x group, despite F11.x being a more stable diagnosis by DSM-5 guidelines (Table 18-11). The mean percentage of members prescribed OAP each month did not markedly decrease after ORD diagnosis by any F11 code, while the percentage of members receiving at least 1 diagnosis of long-term OAP use increased post diagnosis. Compared with diagnosis by any F11 code, members first identified as having ORD via a BUP-MAT prescription for 3 or more days exhibited lower mean PMPM costs, fewer OAPs, and fewer inpatient or ED visits.

Results of this analysis highlight the need for better education around coding practices for ORD and long-term OAP. Accurate measurement of members with ORD is increasingly important given the escalating opioid epidemic. Thus, improvements to standardization are needed for the managed care community to appropriately identify ORD for case management, clinical intervention, or expanding access to care.

Author Affiliations: axialHealthcare (AW, DMS, EAS), Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center (MBP), Nashville, TN; Embold Health, Nashville, TN (MBP).

Source of Funding: axialHealthcare funded acquisition of the research data set.

Author Disclosures: At the time of manuscript acceptance, Dr Watson was employed by axialHealthcare as a clinical pharmacist and scientific writer. Dr Simon was employed by axialHealthcare as a data scientist and has a patent pending on a machine learning model for predicting opioid use disorder. Ms Peratikos was employed by axialHealthcare as director of research. Dr Stringer was employed by axialHealthcare as chief science and clinical officer.

Authorship Information: Concept and design (AW, DMS, MBP, EAS); acquisition of data (EAS); analysis and interpretation of data (AW, DMS, MBP); drafting of the manuscript (AW); critical revision of the manuscript for important intellectual content (DMS, MBP); and supervision (MBP, EAS).

Address Correspondence to: Amber Watson, PharmD, MedLogix Communications, LLC, 2 Pierce Pl, Ste 1150, Itasca, IL 60143. Email:

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