Wiki AUD vs Alcohol dependence or abuse

[Lendee]

According to DSM-5
Code based on current severity: Note for ICD-10-CM codes: If an alcohol intoxication, alcohol withdrawal, or another alcohol-induced mental disorder is also present, do not use the codes below for alcohol use disorder. Instead, the comorbid alcohol use disorder is indicated in the 4th character of the alcohol-induced disorder code (see the coding note for alcohol intoxication, alcohol withdrawal, or a specific alcohol-induced mental disorder). For example, if there is comorbid alcohol intoxication and alcohol use disorder, only the alcohol intoxication code is given, with the 4th character indicating whether the comorbid alcohol use disorder is mild, moderate, or severe: F10.129 for mild alcohol use disorder with alcohol intoxication or FI 0.229 for a moderate or severe alcohol use disorder with alcohol intoxication.
Specify current severity:
305.00 (FI 0.10) Mild: Presence of 2-3 symptoms.
303.90 (FI 0.20) Moderate: Presence of 4-5 symptoms.
303.90 (FI 0.20) Severe: Presence of 6 or more symptoms

With that said, do my providers still need to document alcohol abuse/dependence OR is it ok for them to document AUD Moderate and I can code as F10.20?

Which one trumps ICD-10 or DSM-5?

 

[nickelclaw]

I can't say which one trumps but in I10 under the F10.20 states AUD, moderate and AUD severe so the code would be correct if they document AUD moderate.

 

[TThivierge]

Hi there Lendee,
Your mental health provider should document in their notations of type of substance abuse (alcoholic, smoking, cocaine, pills/drugs, vaping Etc) plus note if it is mild, moderate or dependence or in remission. You should not have to guess. So if the provider documents F10.20 alcohol used disorder uncomplicated, moderate that be okay to use that dx code However are they describing any other complications the pt. has with the AUD? The F10.2 dx block goes into more detailed as if the drinking dependence adds to more pt. problems of sleep disorder, sex dysfunction,depression, bipolar, or hallucinations if documented. Or they can just use the dx codes for each of those pt. issues due to drinking. There is no Excludes 1 Rule except F32 and F31 cannot be listed together. Also the provider needs to distinguish when using pt. has "history of "by adding dates(current or years ago) to help you select the dx code F or Z dx to assign properly. Dependence, abuse, or use with any type of substance abuse in describing on the note should be decided by the providers job knowledge to help you abstracted better. I ve had clinician s just say dx of substance abuse and did not specific what was the problem. Query them, unless put in detailed notations of treatment to help me know the exact problem(cocaine, ciggs, alcohol, pills).
DSM 5 is a guide for the beh. health provider to understand the signs and symptoms of different kinds of mental health illnesses. Thus it is put in notation described pt's signs & symptoms for the medical coder who shall ensure the dx code matches the medical record for the day s treatment in which dx is then assigned by the provider. I agree with Nicole neither trumps the other. These two (ICD10 & DSM5) work in conjunction with each other.
Well I hope I helped you.
Lady T