Coding corner: Improve medical record documentation for alcohol abuse and alcohol dependence

Blue Cross Blue Shield of Michigan follows the Centers for Medicare & Medicaid Services’ ICD-9-CM coding guidelines and American Hospital Association coding clinics to identify supporting documentation for alcohol use. The medical record documentation for alcohol-related conditions isn’t always clear to the reader.

Complete documentation is crucial to accurately report the medical condition, status, severity, and any other conditions that affect or are affected by the abuse or dependence. Medical conditions submitted to CMS are based solely on provider documentation.

It’s important to be specific, too. Complete documentation is essential to determine whether the condition is alcohol abuse or alcohol dependence, known as alcoholism. The following are examples from progress notes that don’t include the diagnosis:

• Patient is aware his drinking is causing problems with family relationships.
• Patient needs a drink to get going in the morning or to unwind after a long day.
• Patient admits to drinking every Friday to get drunk with friends.
• Patient drinks a beer but is finding it difficult to stop at one.

It’s critical that providers take it onestep further and identify the status of alcohol use in their documentation. For example, providers should note if it’s continuous, episodic or in remission. Here are sample situations where additional documentation is needed to identify the status of the condition:

• Patient needs a drink every day to unwind.
• Patient only drinks on Friday to get a high.
• Patient hasn’t had a drink in a week, two weeks, a month or two months.

A review of the past medical history is a critical part of the patient encounter. It’s important to remember the following:

• The progress note must be current and updated with each office visit.
• Actively treating conditions recorded in past medical history must be addressed and documented in the face-to-face encounter.
• When both “abuse” and “dependence” have been recorded, the notes should clearly describe which one is actively being treated. Without this clarification, neither diagnosis can be reported. Note: This differs from the ICD-10-CM coding guidelines. See details below under ICD-10.

“History of” means the condition no longer exists and the patient is no longer receiving any treatment. Providers often use “history of” to signify “ongoing” or “continual” conditions. Without supporting documentation, the status of the condition is unclear and may default to a personal history. The following are examples of the two scenarios:

• Patient has a history of consuming a minimum of six cans of beer daily since age 18. Patient has been sober now for five years and continues with Alcoholics Anonymous program.
• Patient has a history of consuming a minimum of six cans of beer daily since age 18. We discussed in today’s visit how the patient’s drinking continues to affect his overall health.

It’s equally important to review associated medical conditions in the face-to-face encounter. For example:

• Patient is present for annual visit. He’s alcohol dependent and drinks a minimum six cans of beer daily and has done so continuously over the past five years. In today’s visit, it was stressed that his liver damage will worsen if he doesn’t stop drinking.
• Patient is an alcoholic who quit drinking three days ago. He’s complaining of shakiness and anxiety. It was explained that his body has developed a physical dependence and he’s experiencing withdrawal symptoms.

ICD-10
As we anticipate the conversion to ICD-10-CM coding guidelines on Oct. 1, 2015, it’s important to remember that ICD-10-CM includes a more comprehensive index to capture a complete diagnosis, such as alcohol, delirium, with intoxication, in abuse.

Both ICD-10-CM and ICD-9-CM coding guidelines allow onlyone code to be assigned when referring to alcohol use, abuse and dependence. However, with ICD-10-CM, a hierarchy is followed. For example:

• When both “use”and “abuse” are documented, only a code for “abuse” can be reported.
• When both “abuse” and “dependence” are documented, only a code for “dependence” can be reported.

Alcohol documentation should read as “use,” “abuse” or “dependence.” It’s equally important to identify the pattern of use. For example, “uncomplicated,” “intoxication” or “remission.”

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.