Wiki Coding for Drug or Alcohol Abuse

[nikita0872]

We are having a dilemma in our office regarding alcohol or drug use.

If the provider says in the A&P that the patient has alcohol dependence or abuse is that okay to code?

Some of my co workers are saying only if he/she is in a treatment program you can code it.

Some are saying only a Mental Health Care provider can give that diagnosis.


Help!!!

 

[ohn0disaster]

How did they come up with that information, exactly? You do not have to be a mental health provider to document a patient with alcohol dependence or abuse. The patient does not have to be in a program either. Alcoholism is considered a chronic condition. Per the official coding guidelines, chronic diseases should be coded anytime they are documented and addressed in an encounter. So, as long as the documentation is there, it should be coded.

 

[nikita0872]

I am not sure where they came up with that either but I'm glad I have your response! Thank you very much!

 

[ohn0disaster]

Thinking about it in terms of the care given during a patient's visit, the use of alcohol is almost always, if not always, going to have a major bearing on the medical decisions made. Alcohol (and drug) abuse and dependence takes a major toll on the users body and can really effect any aspect of care/treatment/management that a physician may consider.

Now, with that said, there may be rules about alcoholism being first listed diagnosis. I am not sure of this but I'm just using logic here.

 

[Rodolfogomez]

Requirements to code alcoholism in remission

If the physician state in his note: pte with history of chronic alcoholism or history of alcohol dependence. How we should code it?. Alcoholism is a chronic condition so we should code 303.93 or just V11.3, please help us. Thank you