ETOH Abuse
I am auditing a chart where the patient was transferred from ETOH rehab to our acute care hospital d/t afib. The physician did a beautiful job linking the afib, thrombocytopenia, bone marrow suppression and hypomagnesemia to the ETOH abuse. The ETOH abuse was coded as F10.20 Alcohol dependence, uncomplicated and I am questioning that code. I feel the ETOH abuse is complicated and would like to use F10.188 Alcohol Abuse with other alcohol-induced disorders as well as the individual codes for the Afib, thrombocytopenia, the bone marrow suppression and the hypomag because the provider used 'due to' to link each disease to the ETOH. Afib is my PDx and F10.188 would give me a CC. What do you think?
Patty
Patricia M. Vitasinski RN CCDS
Supervisor- Clinical Documentation Specialist
Henry Ford West Bloomfield Hospital
(248) 325-0204 office
Pvitasi2@hfhs.org
Comments
No option for alcohol use without a mental or behavioral issue rolled into it. The following message comes up when you code it:
Psychoactive Substance Use
The codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnosis). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.
Hope this helps!
Amy Stremming, RN, CCDS
Vanderbilt Medical Center
Thanks so much Amy!
patty