Internal Medicine Coding Alert
Decide Dependence, Use, or Abuse Before Reaching for Remission Codes
Question: Our provider documented in the record that she met with a patient who had a history of alcoholism. However, the patient has been sober for a year now. What is the correct way to document the patient's condition? Missouri Subscriber Answer: ICD-10 does not use the term alcoholism. Instead, it differentiates between alcohol abuse (F10.1), dependence (F10.2), and use (F10.9). If your provider has documented one of these terms, then that will determine the code you would use in this scenario; if the chart indicates more than one term, you would code to the highest level of the problem documented. So, if the chart indicates both abuse (the use of alcohol to the detriment of the patient's wellbeing) and dependence (the patient's physical need for alcohol), you would code to dependence, or F10.2. Fortunately, documenting the patient's sobriety is a little easier, as ICD-10 does not distinguish between early or sustained remission. Instead, it only offers one fifth-character option, 1, for any kind of remission. A diagnosis of alcohol dependence in remission, then, would be coded as F10.21.
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