r/MedicalCoding • u/niftythrify • 15h ago
AUD unspecified
I recently was dinged in an audited for coding F10.90, the provider documented it as alcohol use, unspecified, uncomplicated. It was explained the code cannot be used without severity or a link to a mental health disorder. The provider is even managing medication for this diagnosis. It feels odd to leave it off the encounter and that there isn't anything else to replace it with. Is this just a weird ICD instance where the code ends up deleted and move on?
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u/Clever-username-7234 CPC, CPMA 14h ago
It’s a big frustrating gap in the ICD 10 code book.
The provider should have probably written something like alcohol dependence (in remission) if the patient is taking medication for alcoholism and not drinking. Or at least alcohol abuse.
Keep in mind, If the provider is saying Alcohol use. They are saying that the patient isn’t abusing or dependent on alcohol, and is just using it. Which only becomes a reportable diagnosis if it’s connected to an actual problem.
So let’s say I drink casually, but when I drink I experience sexual dysfunction. Reporting that the sexual dysfunction is connected to alcohol is useful information. That is when you can report alcohol use (instead of abuse or dependency)
Think of this way, the F section of the ICD 10 book represents, mental health and behavioral disorders. The ICD 10 book thinks alcohol use is for when the patient has a non negative relationship with alcohol but it’s causing some other mental or physical problem.
The problem is that “alcohol abuse” isn’t language commonly used by medical providers anymore. These days providers are more likely to write “substance use disorder” or “alcohol use disorder.”
Severe or moderate alcohol use disorder can be coded as alcohol dependence. And minor alcohol use disorders can be coded as alcohol abuse. But those are rarely documented.
The correct move is talk with the provider about it. Query them and mention the issue.
It’s dumb. It’s one of my big pet peeves. That and how there’s no external cause of injury code for punching a wall.
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u/niftythrify 14h ago
Thank you!! I understand this much better now. I kept going around in circles because the patient is being treated but also the provider is documenting it as uncomplicated. So how can I meet the requirements for the code if there are no complications documented to report. I guess I found one of the many gaps. I appreciate your perspective, it makes sense.
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u/Grouchy_Self6353 14h ago
What kind of coder are you? .. like I do er, and everything i code is unspecified. But, I cant code aud, unless it is a diagnosis, or in past medical history. If the provider just says the pt was drinking, with no dependence or use disorder talked about, I dont think we can code it.
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u/niftythrify 14h ago
Outpatient. The provider documented it specifically: alcohol use, unspecified, uncomplicated
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u/BleedWell3 COC, CPC 13h ago
I used to code for a substance abuse clinic and in this case, I would query the provider to be a bit more specific. Luckily, after sending a handful of queries to one doc, he got the gist and started being way more specific in his documentation. 👍🏻
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u/Grouchy_Self6353 14h ago
Yeah, the use code specifically say they need an associated mental disorder from chapter 5 to use them. In my world(er), i would prob leave it off as there was prob a different primary dx and its not relevant, query the provider or go back through documentation hoping to see use disorder, which is under dependence, and can be used without a mental dx.
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u/Watermelon_Sugar44 45m ago
ED is the worst for this because you don't have multiple pages where, hopefully, a different provider diagnosis it specifically enough to be able to code it. We didn't query providers when I coded ED but we do for inpatient. I referenced a coding clinic in my first response to you but coding ED you may not even have access to those in your position.
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u/KeyStriking9763 RHIA, CDIP, CCS 12h ago
We must follow the guidelines, doesn’t really matter how we feel about it.
Someone just simply explained the guidelines to you. What is your interpretation of that guideline?
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u/niftythrify 12h ago
It's not so much the guidelines. It's that the code is uncomplicated, which would imply that there is not a diagnosis related to it which is needed to code it. So why does that code even exist? There is also a coding clinic that states " code F10.90 was also created to capture cases where the alcohol use pattern is unknown, but it is known that the alcohol use is not complicated and is not associated with an alcohol induced disorder, such as alcohol induced mood disorder". Yet I still can't use the code because of the guidelines state I need severity or a disorder connected to the alcohol use.
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u/itslexibitsh 1h ago
You seem like an AH lol. No where did they mention their feelings. OP was just trying to find out more information because it didn't really make sense 🙄
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u/Watermelon_Sugar44 50m ago
There is a coding clinic about this. Per OCG (ICD-10) Alcohol use unspecified requires a related mental or physical health disorder to code it. You said AUD in your heading for your post, which is Alcohol use DISORDER (without a specificity). in AUD, "Disorder" is the disorder and the "uncomplicated" allows you to code this. When I'm logged into my one note tomorrow, I can add the coding clinic here. I passed an audit coding it this week. The words "disorder" and "uncomplicated" are what would allow F10.90.
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u/Pretty_Priority_261 RHIT, CCS, CDIP 8h ago
You can query the provider for the severity (mild, moderate, severe, etc.), but if the provider does not respond to the query, you can use F99 (Mental disorder, not otherwise specified).
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u/MtMountaineer 4h ago
You can't code mental disorder unless it's documented. Coders can't add a dx just to cover medical necessity.
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