Primary Care Coding Alert

Question: The provider recently documented occasional alcohol use in the social history section of the patient’s medical record. Is this a situation where I’d use the new code for unspecified alcohol use, F10.90?

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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 section of a medical record addresses anything having to do with the patient’s job, family, diet and exercise habits, and recreational habits that could at some point be considered clinically significant. Occasional alcohol use certainly fits in this section, but whether it’s clinically significant at this encounter isn’t clear.

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 — as long as the provider has thoroughly documented the patient assessment and included reducing alcohol consumption as part of the obesity management plan.