Wiki Alcohol ingestion

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sheardmd

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I am a long time coder, but I am new to ER coding so this was a stumper to me for a diagnosis code.

Twelve-year old patient presented to the ER after mother discovered that patient had been ingesting alcohol before school every morning. Patient had no SI and no other documented psych problems. Patient was not intoxicated. Patient did test positive for ethanol and methanphetamine.

Any help would be appreciated.

Thanks!
 
what was the reason for the ER encounter? If the provider does not document that the patient is an alcohol user/abuser then that cannot be coded, also the lab showed positive for the ethanol and meth(disturbing to say the least!) the provider will need to document whether that indicates a drug issue such as abuse or dependence.
 
The mother brought him in due to the above-mentioned behavior. Dr lists final diagnosis as alcohol ingestion. In the ROS he did mention impulsivity. There is nothing else there.

Since I was at a total loss on this I coded the chief complaint as: 312.9 and the Final diagnosis as: 1) 312.9 2)799.23. I am sure that these codes are probably not correct, but I wasn't sure what else to do.
 
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