July 5, 2024

Alcohol Use, Abuse, and Dependence in Medical Coding

By Janine Mothershed

Alcohol Use, Abuse, and Dependence Codes

When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
  1. If both use and abuse are documented, assign only the code for abuse
  2. If both abuse and dependence are documented, assign only the code for dependence
  3. If use, abuse, and dependence are all documented, assign only the code for dependence
  4. If a patient presents with both abuse and dependence, code for dependence as it is the more severe condition

https://www.aapc.com/blog/37012-code-to-the-highest-severity-for-drug-use-abuse-and-dependence/

Psychoactive Substance Use, Abuse and Dependence

A code from code section F10.- would be reported for a diagnosis of alcohol use, abuse, or dependence. Mental, Behavioral and Neurodevelopmental Disorders (F01–F99) codes are found in Chapter 5 of ICD-10-CM. Possible ICD-10 codes linked to the counseling and office visit code as follows:

  • Code: F10.9-
  • Description: Alcohol use, unspecified
  • Code: F10.1-
  • Description: Alcohol abuse
  • Code: F10.2-
  • Description: Alcohol dependence

Personal History of Alcohol Abuse and Dependence

  • Code: Z86.59
  • Description: Personal history of other mental and behavioral disorders

Family History of Alcohol Abuse and Dependence

  • Code: Z81.1
  • Description: Family History of Alcohol Abuse and Dependence

Alcohol Abuse Counseling

  • Code: Z71.41
  • Description: Alcohol abuse counseling and surveillance of alcoholic (use additional code for alcohol abuse or dependence (F10.-)

Psychoactive Substance Use, Unspecified

As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.

Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence

Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder.

Blood Alcohol Level

A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded.

https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines-updated-02/01/2024.pdf

In Remission

Selection of codes describing “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.11, -.21, -.91) requires the provider’s clinical judgment and are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.

Procedure codes such as evaluation and management (E/M) codes are a method of documenting what service or procedure was performed. The most appropriate E/M code to select will depend on whether the encounter was for screening or treatment of the condition. If the encounter was for screening the patient, report a preventive medicine code. These codes are selected according to the time spent in face-to-face counseling with the patient. Whether or not these codes will be reimbursed by the payer will vary. Possible procedure codes are the following:

  • Code: 99401-99404
  • Description: Preventive medicine, individual counseling
  • Code: 99411-99412
  • Description: Preventive medicine, group counseling

Specific CPT codes have been developed for alcohol abuse counseling. These services are reported as follows:

  • Code: 99408
  • Description: Alcohol and/or substance abuse, structured (eg, AUDIT, DAST), and brief intervention (SBI) service; 15 to 30 minutes (Do not report services of less than 15 minutes with 99408)
  • Code: 99409
  • Description: Alcohol and/or substance abuse, structured (eg, AUDIT, DAST), and brief intervention (SBI) service; Greater than 30 minutes (Do not report 99409 in conjunction with 99408. Use 99408 or 99409 only for initial screening and brief intervention)

If the encounter was for treatment for a patient with a diagnosis of alcohol use, abuse or dependence, report an office or other outpatient E/M code. These codes list a “typical time” in the code descriptions. Codes with typical times listed may be reported based on time, rather than the key E/M components of history, examination, and medical decision-making. If the health care professional spends more than 50% of the visit counseling the patient, the E/M code may be selected based on time. Time spent providing face-to-face counseling with the patient must be documented in the medical record. The record should document total time and that either all the encounter or more than 50% of the total time was spent counseling the patient. The patient record must also provide details on the topics discussed. Possible procedure codes are the following:

  • Code: 99201-99205
  • Description: New patient, office, or other outpatient visit
  • Code: 99211-99215
  • Description: Established patient, office, or other outpatient visit

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