Wiki Alcoholic Cirrhosis

[deltaluv]

Does the doctor have to document alcohol use in the chart to code dependence as the secondary code to Alcoholic Cirrhosis?

 

[Pam Warren]

When the provider documentation refers to use, abuse, and dependence of the same substance (e.g., alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:

• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence

But you do need to have documentation of the use/abuse/dependence in order to code it secondarily.