bridgettemartin
Expert
I am seeking an opinion from an auditor. I posted this in another forum and am wondering what guidance can be offered and if there is a resource out there that addresses this scenario specifically.
We are instructed that whenever more than one classification of drug/alcohol use is mentioned, that we code the higher level. For instance, if abuse and dependence are both mentioned, we code only dependence. That being said, does anyone have a reference that mentions what to do when both are mentioned in the note, but only one is listed under the Assessment or Dx portion of the note?
For instance---I have a Psychiatric admission note that goes into detail about the patient's dependence and alcohol consumption. But, when the Provider lists the actual admitting dx he states 'Alcohol Use Disorder' which aligns with DSM. I have both listed in the documentation, but he doesn't state dependence under the admitting dx. I have no problem querying the provider, but wondering if since both are mentioned in his documentation, but only 'use' mentioned as the dx, if I would need to.
Much appreciated!
We are instructed that whenever more than one classification of drug/alcohol use is mentioned, that we code the higher level. For instance, if abuse and dependence are both mentioned, we code only dependence. That being said, does anyone have a reference that mentions what to do when both are mentioned in the note, but only one is listed under the Assessment or Dx portion of the note?
For instance---I have a Psychiatric admission note that goes into detail about the patient's dependence and alcohol consumption. But, when the Provider lists the actual admitting dx he states 'Alcohol Use Disorder' which aligns with DSM. I have both listed in the documentation, but he doesn't state dependence under the admitting dx. I have no problem querying the provider, but wondering if since both are mentioned in his documentation, but only 'use' mentioned as the dx, if I would need to.
Much appreciated!