Wiki Use vs Abuse vs Dependence

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bridgettemartin

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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, if I would need to.

Much appreciated!
 
We can code fm anywhere in progress notes if documentation supports it, doesn't have to be frm assessment section only. Since he mentioned dependence and pt is being admitted fr alcoholism, I would capture it.
 
I agree with sujaya you can abstract information form the entire note for diagnosis. Below are the ICD-10 Guidelines:
ICD-10-CM Official Guidelines for Coding and Reporting

• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence.
 
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