Tobacco use D/O NOS???

[nancysinatra]

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I saw this on a psych consult note for a medicine patient today. Does such a classification actually exist? I don't think the doctor here was saying anything more than that the patient has a 20 PY smoking history. Can doctors just label anything they want to as a disorder, even if it's fairly ordinary behavior? So for example, could lateness to a doctor's appointment then become Punctuality d/o NOS? Or is smoking really now a mental illness?

This brings up another question. How come psychiatry has the DSM with its numbered diagnoses, but you don't see this in other fields? Once I did see a medicine admit note with numbers next to the diagnoses, and I wondered if this meant that there was a medicine textbook somewhere where all the diseases would be neatly indexed by number. But it was only that once that I saw it.

If this question sounds silly, forgive me--remember, I am the person who until recently thought "malingering" was an official disease. I need all the information I can get.

 

[manwhoisthursdy]

Nicotine dependence, withdrawal, and "nicotine related disorder NOS" are all in the DSM. Nicotine use may be common ('ordinary') but certainly it is addictive, making it very very tough to quit even if you want to. Trying to quit can lead to distressing withdrawal symptoms as well ... so clearly there are times when a disorder can/should be diagnosed.

Medicine and Surgery don't have, to my knowledge, numbers for each disease in the same way, because their standard or communication, rather than based upon a Nomenclature Committee's current consensus, tends to be based upon much more easily objectively observed physical exam criteria, or histopath, or abnormal lab tests. But that's far from always the case, and I can think of some medical disorders, such as Kawasaki's, or Rheumatic Fever, for which internists/pediatricians/etc have agreed upon criteria to define the disease.

There are other examples ... what is diabetes? When is it hypertension? How many joints for polyarthritis? There's no one single book, but there are the consensus opinions of the FACC, the ACP, the AAFP, the ADA, etc.

 

[OldPsychDoc]

Actually, though, every diagnosis does have an associated ICD code number for various billing and administrative purposes. Check out the fine print on your clinic's billing forms. 🙁

 

[nancysinatra]

Nicotine dependence, withdrawal, and "nicotine related disorder NOS" are all in the DSM. Nicotine use may be common ('ordinary') but certainly it is addictive, making it very very tough to quit even if you want to. Trying to quit can lead to distressing withdrawal symptoms as well ... so clearly there are times when a disorder can/should be diagnosed.

Ok, that makes sense. Also along those same lines, no one disputes whether lung cancer--which is like addiction (or withdrawal, etc.) in that it can be a sequela of smoking--should be an official diagnosis, regardless of how "ordinary" smoking is. The thing about this consult note, though, was that it made no mention of any discussion with the pt about his past or present tobacco use. The way it was phrased just seemed like a euphemism where instead they could have stated a pack-year history.

I wonder what would land a pt in the NOS category for nicotine dependence? But anyway, this was "tobacco use d/o," not nicotine dependence. (And there was no number!) I couldn't help but picture someone holding their cigarette the wrong way or puffing badly, and that being the basis of a "disorder."

Out of the blue someone explained those billing codes to me tonight. So now I know. I got thinking about this because I have a pt with mesothelioma, and I was wondering whether it was epithelioid or sarcomatoid. Path never told us that. So I was looking this up and it turns out you can get WAY more specific than that. And this must apply to every cancer. I just wonder how many decimals the code would start to have if you really tried to pin it down.

 

[manwhoisthursdy]

Actually, though, every diagnosis does have an associated ICD code number for various billing and administrative purposes. Check out the fine print on your clinic's billing forms. 🙁

OPD ... do you know where these billing codes come from? Are they meant to in any way define or classify anew (like the APA does in the DSM), or are they just meant to include diagnoses already being made, without trying to make any statements in the way things are classified and broken down?

 

[OldPsychDoc]

OPD ... do you know where these billing codes come from? Are they meant to in any way define or classify anew (like the APA does in the DSM), or are they just meant to include diagnoses already being made, without trying to make any statements in the way things are classified and broken down?

When all else fails, consult Wikipedia. 😳
Basically, unlike the DSM, they are just numbers assigned for reporting purposes.

(And yes, I did endure a lecture about this during my residency. And yes, my eyes did glaze over. And no, I didn't learn a d*** thing!)

 

[whopper]

Out of the blue someone explained those billing codes to me tonight. So now I know.

Funny. Several places I worked at as a student--they expected me to do these but only after maybe the 15th request did someone explain how to do them.

 

[billypilgrim37]

do you know where these billing codes come from?

The intent of the ICD-9 (which I believe was published roughly the same time as the DSM-III was certainly to define and distinguish disorders just as the DSM does now. The ICD-8, like the DSM-II, focused decidedly on more analytic terminology. Spitzer and Co made sure that the DSM-III would take care of much analytic presence in our nosology, for better or worse (I'd say better, but hey). The DSM-III so greatly dominated diagnostics that ICD-9 basically adopted much of its terminology, and ICD-10, which the US hasn't quite caught up with, further mirrors our current DSM terminology.

The ICD billing codes are convenient because they span all medical specialties, and I'm pretty sure when the WHO publishes all its psych epidemiology, it's using ICD criteria (which occasionally differ from DSM criteria in ways that do effect the sort of numbers you see).