alcoholism/alcohol abuse

ggparker14

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Patient presents to ED with BAC 0.331. Physician documents alcoholism/alcohol abuse. Would 303.91 be the correct code here?


Thanks for any help.
 

jojo2922

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I would use 303.91 unless somewhere in the documentation the doctor says the patient is currently intoxicated then you could use 303.01.
 

LTibbetts

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I would actually use the 30390, unless the physician specifically documents the use of alcohol every day. Although, the term alcoholism leads you to believe that the patients abuses alcohol daily, we can not make that assumption. For "continuous" use, the provider must state that the patient uses alcohol every day (i.e. a six-pack a day, etc) -per coding clincs.


Fifth-Digit Subclassification

A fifth-digit subclassification is provided for categories 303--305 to indicate the patient's pattern of use:

-0: unspecified

-1: continuous: Alcohol: refers to daily intake of large amounts of alcohol or regular heavy drinking on weekends or days off from work

Drugs: daily or almost daily use of drug

-2: episodic: Alcohol: refers to alcoholic binges lasting weeks or months, followed by long periods of sobriety
Drugs: indicates short periods between drug use or use on weekends

-3: remission: Refers to either a complete cessation of alcohol or drug intake or to the period during which a decrease toward cessation is taking place

The coder should not attempt to apply these digits without the pattern of use being documented in the medical record. It is common for technical and professional personnel other than the attending physician to provide much of the documentation in facilities dealing with detoxification and rehabilitation, and it is appropriate to accept this documentation for the purpose of assigning fifth digits.




©*Copyright 1984-2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
 
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