Home Health ICD-9/ICD-10 Alert

Question: Our new patient's medical record reads, "Cirrhosis likely secondary to alcohol dependency." Which cirrhosis diagnosis code should I use? Should I use alcoholic cirrhosis (571.2) because the physician mentioned this as a likely cause? Or should I use cirrhosis without mention of alcohol (571.5)?

Answer: Because the physician is not sure this is alcoholic cirrhosis,you should not code it as such, so you should use 571.5. This practice safeguards the patient as well. If it turns out that it is not alcoholic cirrhosis, you have falsely labeled that patient as alcohol-dependent. Query the physician for a more definitive diagnosis.