History of alcohol abuse

[leastratton1001]

How are you capturing history of alcohol abuse. The alpha for personal history of substance abuse NEC directs us back to F10-F19, Guidelines indicate we must have provider documentation to code in remission. Does this need queried to clarify if its current or in remission?

 

[TThivierge]

Hi Leastratton,
Yes the therapist of doctor must write remission of any kind of drug abuse or use the wording. Provider could state patient had history of alcoholism stopped in last 3 months but started again. So the patient still suffering with AUD as example. Recovery is a process through which an individual pursues both remission from AUD and cessation from heavy drinking. Recovery can also be considered an outcome such that an individual may be considered ‘recovered’ if both remission from AUD and cessation from heavy drinking are achieved and maintained over time. Hopefully the provider will add this in documentation. Remission was defined as no longer meeting DSM-IV criteria for an alcohol or drug dependence disorder past 12 months or a year. Follow dx assigned by provider as Use vs Abuse vs Dependency . See dx F10.21 Alcohol use in remission. The new dx codes add words "remission & recurrents"to sub abuses now even in Depression illnesses.
Well hope helped you a little bit.
Lady T