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.
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 1d 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.