Alcohol abuse
We have a patient that was admitted for alcohol induced acute pancreatitis. This is his 10th admission with the same diagnosis. The hospitalist did document alcohol abuse and stated that will order Ativan prn due to hallucination during the last admission while withdrawing. There was no documentation of withdrawal symptoms during this stay. A history of anxiety is documented, and the patient did require Ativan during this visit for anxiety. The coder coded a secondary DX of F10.239 Alcohol dependence with withdrawal unspecified for this visit. Is that the correct code since there is no documentation of withdrawal for this visit? Also, should I query to link the anxiety and alcohol abuse? If so, can someone give me a query example? Thanks for any help.
Comments
There is a brand new Coding Clinic 1st Quarter 2018 that may help you it basically states that in ICD-10-CM withdrawal is only classified at the level of dependence and if the physician documents both alcohol abuse and withdrawal we would query for the clarification of the "abuse" and if that is the appropriate diagnosis we would only code the "alcohol abuse" and not the withdrawal. As far as the anxiety is concerned we cannot assume it is related to the alcohol abuse a query would be needed to have it linked.
Dear Doctor,
(patients name) admitted for alcohol induce acute pancreatitis documentation includes a history of anxiety(where you found the information) requiring Ativan (date and dose) with alcohol abuse documented on (where and when) based on information provided can you please document below if the anxiety is related to the alcohol abuse.
A. yes
B. No
C. unable to determine
D. other
_____________________________________________
if your physicians are not allowed to answer directly on the query form itself you would have to reword the question a little bit and ask them to document their response in their next progress note and/or discharge summary.