Wiki Alcohol Use

[Csjohnson91]

If you have patient that comes in with occasional alcohol use what code would you use? Provider documented it under social history. Is it the coders discretion to code or not? And if I chose not to code it would I be out of compliance?

 

[thomas7331]

Alcohol use that is not related to any specific disorder is coded as Z72.89 - Other problems related to lifestyle. As with any code, it should only be assigned and reported when the record shows that the condition requires or affects treatment at the current encounter, so I would not code it if it is only mentioned in the history and is not otherwise documented as being relevant to the care.

Per the ICD-10 guidelines, C.5.b.3, the codes in the F10 category for alcohol use, abuse and dependence "are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider." So those codes are not appropriate for simply reporting alcohol use that is not otherwise contributing to a medical disorder.

 

[jkyles]

If you have patient that comes in with occasional alcohol use what code would you use? Provider documented it under social history. Is it the coders discretion to code or not? And if I chose not to code it would I be out of compliance?

Hi there, occasional use of alcohol doesn't have a diagnosis code.

 

[alvesey]

What is a scenario in which the "unspecified use" codes would be appropriate to report? For example, F10.90, F11.90, F12.90, etc.? Would it be a situation where the provider doesn't know whether the use qualifies as abuse or dependence? What kinds of substance related disorder or medical disorder would apply? Thanks for any and all help!

 

[kdlberg]

What is a scenario in which the "unspecified use" codes would be appropriate to report? For example, F10.90, F11.90, F12.90, etc.? Would it be a situation where the provider doesn't know whether the use qualifies as abuse or dependence? What kinds of substance related disorder or medical disorder would apply? Thanks for any and all help!

"Use" would be appropriate when it's documented as such, and not as abuse or dependence. I know that's not a very good answer, but it's the provider's judgement that determines which one to use. Meaning if the provider believes it's dependence, it is, and that's what they should state. I tell my clients that if they code abuse instead of dependence, or use instead of abuse, the Documentation Police aren't going to put them in Documentation Jail.

And again, unless it's stated that it affects their health/lifestyle in some way--which means there is an assessment and plan that goes with the dx--it shouldn't be coded.