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"History of" and "Versus" codes

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mollie77

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Forgive me, I'm new at this.....An Inpatient axis I reads: history of paranoid schizophrenia and alcohol abuse versus alcohol dependence. How do I code this?? Thanks!
 
For the schizophrenia history, it's sometimes difficult to tell if the provider is still managing the condition. However, if it's listed on Axis I and there is not Axis II that is being concurrently managed, I'd code the schizophrenia. You can query the provider just to be sure.

For dependence versus abuse, there are no outpatient ICD guidelines that cover that circumstance. While abuse is the "lesser" of the two, I'd query the provider certainly in that case to ensure that the proper code is being assigned. If the provider will not or cannot make a determination about abuse vs dependence, I'd refrain from coding either.

Hope this makes sense.
 
If it is inpatient facility, the schizophrenia would be coded if managed, treated or observed. The provider would have to be queried about the abuse versus dependence, assuming it is a secondary diagnosis for the stay.

In the event that the dependence or abuse is, in fact, the Principal Diagnosis for the case, then the Coder would need to reference Section II, D. of the Official ICD-9 Coding Guidelines.

Good luck to you!
 
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