Sedatv/hyp/anxiolytc dependence w withdrawal delirium

This diagnosis indicates a severe substance use disorder characterized by physiological dependence on sedatives, hypnotics, or anxiolytics, coupled with the presence of withdrawal delirium. Patients experience significant cognitive and perceptual disturbances, such as disorientation, hallucinations, and fluctuating levels of consciousness, specifically during withdrawal from these substances. This is a life-threatening condition requiring immediate medical intervention.

Apply this code when documentation clearly states dependence on sedatives, hypnotics, or anxiolytics and explicitly describes symptoms consistent with delirium occurring during withdrawal. This typically arises in inpatient settings or emergency departments where patients are undergoing detoxification or experiencing acute withdrawal complications. Supporting documentation includes physician notes detailing substance use history, mental status exams, and diagnostic criteria for delirium.

• Ensure documentation specifies "dependence" rather than "abuse" or "use" to justify the .2 category.
• Confirm the presence of delirium symptoms (e.g., disorientation, hallucinations, altered consciousness) directly linked to withdrawal.
• Sequence this code as the primary diagnosis when the withdrawal delirium is the main reason for the encounter.