Nicotine Dependence and the ICD-10 Classification System

While nicotine dependence is traditionally associated with cigarette smoking, the rapid rise of the e-cigarette market had contributed to over 58.1 million non-tobacco-using nicotine addicts worldwide by 2018. A dual-action stimulant and depressant, nicotine is one of the most commonly used substances, ranking alongside alcohol, caffeine, and cannabis. 

Despite years of public service media campaigns advertising the harmful side effects of nicotine, dependence on the chemical remains a problem across the United States and virtually every other part of the globe. The recent e-vaping trend concerns many health professionals for several reasons. We will provide a general overview of the ICD-10 codes and their medical utility before illustrating how to use the classification system for diagnosing nicotine dependence. 

What Are ICD-10 Codes, and Why Do We Use Them?

The International Classification of Diseases (ICD) is a globally recognized disease cataloging system updated and published by The World Health Organization (WHO). Its initial renditions date back to the late 18th century with European physicians such as Dr François Bossier de Sauvages de Lacroix and William Cullen. 

Cullen published a document titled “Synopsis nosologiae methodicae” that sought to classify several common diseases. Sauvages de Lacroix engaged in a similar disease classification project, borrowing from the then-popular botanical methods to develop his own list that would later become important in the early cataloging system documenting vitality records. 

Clinicians used this schema until the 19th century, when William Farr, a medical statistician in the General Register Office of England and Wales, amended it to reflect a more uniform system for international recordkeeping. He focused on developing a universal nomenclature for categorizing diseases and causes of death that had more international utility for capturing statistics across the globe’s various languages and cultures. 

Farr’s classification system later became known as The International List of Causes of Death. This system merged the causes of morbidity and was subsequently adopted by The World Health Organization (WHO) as the International Classification for Disease in 1948. 

It included the modern coding system found in ICD-10. Since that time, WHO has published and periodically updated the existing ICD system, typically every decade, to align with medical advances and modern approaches to healthcare. 

WHO began working on the 10th revision of The International Disease Classification in the 1990s. In the U.S., on Oct. 1, 2015, after several extended delays, ICD-10 replaced the 9th revision first issued in 1977. While the 9th edition allowed clinicians and providers to capture more detailed morbidity and update more frequently, the 10th revision expanded the codes substantially from 17,000 to 155,000.

The hierarchical structures in ICD-9 and ICD-10 are virtually the same. The first three digits in the code represent common disease traits. The latter characters indicate a range of specified conditions. 

While ICD-10 and ICD-10-Clinical Modification (CM) are often used interchangeably, they draw from different statistical pools. The ICD-10, for instance, relies on information on death certificates. ICD-10-CM, on the other hand, uses information from hospitals, clinics, surveys, and inpatient procedural statistics for its aggregate morbidity data.

After an initial open comment stage in the early and mid-1990s, ICD-10 was approved for its initial implementation in 1999 for reporting global mortality data. ICD-10 includes more classifications, but it also gives healthcare providers more subcategories that include more detailed descriptions of the many thousands of disease classifications. 

The additional categories provide additional space for indicating the type and site of the disease. The ICD-10 also uses alphanumeric code, in contrast to the all-numeric code in ICD-9, similarly distinguishing the newer system from previous revisions. 

ICD-10’s more sophisticated alphanumeric code benefits healthcare providers in the following ways:

  • More detailed standardized documentation methods
  • Clarity and uniformity in client records
  • Streamlined communication in all aspects of healthcare
  • Improved worldwide statistical analysis
  • Increased precision on billing and reimbursement
  • Fewer misdiagnoses and treatment errors

The transition from ICD-9 to ICD-10 is regarded as a significant advancement in the history of disease classification. The updated ICD-10 system provides greater specificity, assisting doctors and healthcare providers to arrive at a precise diagnosis. The ICD-9 codes were considered too broad and didn’t allow for exacting data inquiries that modern healthcare venues require. 

The codes contained in the ICD-9 system weren’t long enough to account for the latest advances in medical technology. At the same time, providers needed more concise, high-quality data to compare the costs against the outcome of the various procedures and technologies used in the treatment. The ICD-10 system, along with any subsequent revisions thereto, helps streamline medical research inquiries while ensuring the safest and most efficient care possible. 

The Nicotine and Tobacco Use Health Crisis in the US

According to the National Institute on Drug Abuse, the scope of nicotine addiction is immense, impacting 23.6 million people 12 or older across the U.S. The health organization defines nicotine dependence as feeling the compulsion to use the drug in the past 30 days. 

The Centers for Disease Control and Prevention (CDC) estimates that 28.3 million U.S. adults smoke cigarettes, while 2.8 million high school and middle school students in the country use some form of nicotine. An increasing percentage of both groups have developed a nicotine addiction after trying e-cigarettes. 

While nicotine addiction through new delivery systems has sharply risen, nearly half a million Americans still die every year as a result of smoking or exposure to secondhand smoke, according to the CDC. The agency says nicotine dependence continues to cost the healthcare industry approximately $225 billion annually to treat smoking-related diseases. 

Nicotine Dependence and the E-Cigarette Epidemic

New nicotine delivery systems, most notably e-cigarettes, have shifted the conversation around nicotine addiction in recent years. Nicotine vaping has reinvigorated concerns among many as to whether or not nicotine in vaporized form is actually safe. Medical experts at Johns Hopkins Medicine state that while vaping is less harmful than tobacco smoking, it’s not entirely without risk. 

Regular cigarettes contain up to 7,000 toxic chemicals, at least 69 of which have been identified as cancer-causing substances. The challenge with e-cigarettes, however, is that, as a newer nicotine delivery system, not much is known about the effects of ingesting chemicals found in vape juice, the nicotine extract e-cigarette that users inhale. 

E-cigarettes undoubtedly contain fewer chemicals than tobacco, but recent outbreaks of lung injuries attributable to vaping tell doctors that there are serious risks associated with e-cigarettes. The CDC and American Lung Association refer to these kinds of vaping use-associated injuries as E-Cigarette or Vaping Use-Associated Lung Injury (EVALI).

Originally known as VAPI or vaping-associated pulmonary illness, both health agencies have observed a growing number of severe lung illnesses related to e-cigarettes and vaping products. The research into what exactly causes lung diseases linked to vaping is still ongoing because the outbreak was only recently identified in 2019

Medical researchers suspect that vitamin E acetate is one of the primary causes of the 2019 spike in vaping-associated pulmonary illnesses. The CDC found that bronchoalveolar lavage (BAL) fluid in a substantial percentage of the studied clients contained vitamin E acetate. This substance, in comparison, was not present in the BAL fluids of otherwise healthy people. 

While the standard forms of smoking remain a problem, and the associated risks are widely known, U.S. health officials continue to grapple with e-cigarette-related nicotine addiction. In 2018, then Surgeon General Jerome Adams declared e-cigarette use among young people a nationwide health epidemic. 

Apart from the inhalation of foreign substances like vitamin acetate and aerosols, he cited the impacts that nicotine exposure can have on the brain during adolescence as a major concern. According to medical experts, the human brain continues developing until age 25. Even alternate nicotine delivery methods such as e-vaping can hamper brain development in young people. 

In addition, some evidence from the National Academy of Sciences and Engineering concludes that adults who use e-cigarettes to transition out of smoking may increase the intensity of their cigarette habits if they relapse. There also exists the possibility that younger people who start their nicotine habits with vaping may develop an affinity for tobacco and adopt the more dangerous form of nicotine dependency. 

Nonetheless, vaping is still very risky. Depending on the severity of EVALI, e-cigarette users can end up in the hospital. Some clients even died during the outbreak. Less severe cases of EVALI can require supplemental oxygen to help clients respirate on their own. Even after a diseased client regains the ability to breathe, there exists a high probability of relapse from the hospital within 48 hours after discharge.

U.S. health officials continue to urge parents to remain proactive by warning their children about the potential dangers of developing a nicotine addiction through e-vaping. Doctors still know very little about the long-term effects, and diagnosing and treating e-cigarette-related diseases are still in the trial-and-error stages of development. 

What Are the Specific ICD-10 Codes for Diagnosing Nicotine Dependence?

The different types of nicotine use disorder are classified under the F17.2 code and its various subclassifications. These detailed coding alphanumeric codes assist clinicians and healthcare providers in painting an accurate picture of a client’s nicotine habits. 

The codes also help monitor the process of treating the client more effectively as they document multiple states of nicotine dependency. The subcategories below each primary category convey varying forms of dependence, from acute withdrawal symptoms to remission status. They also cover undefined or “other” nicotine use disorders.

The following codes under the F17.2 for nicotine dependence help providers develop the appropriate nicotine cessation plans while streamlining more accurate insurance billing and public health data collection: 

Here are codes clinicians and healthcare specialists rely on the tools to communicate a nuanced picture of a client’s nicotine addiction: 

F17.200: Nicotine dependence, unspecified, uncomplicated

This initial classification indicates a general state of nicotine dependence. The subcategories are:

  • F17.201 – Nicotine dependence, unspecified, in remission
  • F17.203 – Nicotine dependence, unspecified, with withdrawal
  • F17.208 – Nicotine dependence, unspecified, with other nicotine-induced disorders 
  • F17.209 – Nicotine dependence, unspecified, with unspecified nicotine-induced disorders

F17.210: Nicotine dependence, cigarettes, uncomplicated

This category describes a cigarette-related addiction to nicotine. The subcategories break down as follows: 

  • F17.211 – Nicotine dependence, cigarettes, in remission 
  • F17.213 – Nicotine dependence, cigarettes, with withdrawal
  • F17.218 – Nicotine dependence, cigarettes, with other nicotine-induced disorders
  • F17.219 – Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders

F17.220: Nicotine dependence, chewing tobacco, uncomplicated

This classification covers nicotine addiction delivered through chewing tobacco. Here is how ICD-10 subcategorizes this condition:

  • F17.221 – Nicotine dependence, chewing tobacco, in remission
  • F17.223 – Nicotine dependence, chewing tobacco, with withdrawal
  • F17.228 – Nicotine dependence, chewing tobacco, with other nicotine-induced disorders
  • F17.229 – Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders

F17.290: Nicotine dependence, other tobacco product, uncomplicated

This code, at present, would be used for alternative delivery systems such as e-cigarettes.

Clinicians use these categories to further detail this state of nicotine dependency:

  • F17.291 – Nicotine dependence, other tobacco products, in remission
  • F17.293 – Nicotine dependence, other tobacco products, with withdrawal
  • F17.298 – Nicotine dependence, other tobacco product, with other nicotine-induced
  • F17.299 – Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders

For a more comprehensive overview of what each character in the code signifies, consult the CDC’s ICD-10-CM browser tool. WHO is currently revising and improving the existing coding for the 11th revision. As additional research comes into view, clinicians can reasonably expect more detailed information concerning e-cigarette dependency in the forthcoming ICD-11 publication.

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