Some Specificity Needed for Alcohol Use Reporting
Question: My practitioner recently documented “occasional alcohol use” in the social history section of a patient’s medical record. Is this a scenario where I would use the code for unspecified alcohol use, F10.90? Wisconsin Subscriber Answer: In this situation, there doesn’t immediately seem to be a reason to code F10.90 (Alcohol use, unspecified, uncomplicated), but it’s hard to know for sure without more details from the medical record. The social history portion of a patient’s medical record encompasses all aspects related to their occupation, family relationships, dietary and physical activity, and any leisure activities that could potentially have clinical relevance. The occasional consumption of alcohol would be included in this section, though its clinical significance during this consultation is uncertain. ICD-10-CM Official Guideline I.C.5.b.3 tells you that codes from F10.9- (Alcohol use, unspecified) “…are to be used only when the psychoactive substance use is associated with a substance related disorder… or medical condition, and such a relationship is documented by the provider.” In other words, if the provider is not linking the patient’s alcohol use with another condition or disorder, there’s no need to report it. For example, if the provider diagnoses a patient with a condition such as obesity and specifically states that the patient’s drinking affects their health or lifestyle, you can report a code such as F10.90 to accompany the diagnosis — if the provider has thoroughly documented this in the patient assessment and has included reducing alcohol consumption as part of their obesity management plan. Lindsey Bush, BA, MA, CPC, Development Editor, AAPC
