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Substance use and 5th digit

  1. #1
    Location
    Bennington, VT
    Posts
    34
    Default Substance use and 5th digit
    Medical Coding Books
    Patient uses opoid, 2 bundles per week and is alcohol dependent with a use of 1 pint vodka per day.

    In view of the Coding Clinic that was published in April 2010, how does one interpret the instruction? Does the provider need to document the actual word (s); continuous, episodic or in remission?

    Thank you.

  2. Default Substance use and 5th digit
    Patient uses opoid, 2 bundles per week and is alcohol dependent with a use of 1 pint vodka per day.

    In view of the Coding Clinic that was published in April 2010, how does one interpret the instruction? Does the provider need to document the actual word (s); continuous, episodic or in remission?

    I work for a state hospital, and the answer is yes. If the notes are not specific, you have to either query the provider or code it as unspecified.

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