Alcohol dependence, also called “alcoholism,” is a chronic disease. Alcohol dependence and abuse affects about 18 million people alone in United states.  In general, men are more likely than women to drink excessively. 

ICD-10-CM includes codes for alcohol use, abuse and dependence. Code categories related to alcohol use are alcohol abuse (F10.1-), alcohol dependence (F10.2-), and unspecified alcohol use (F10.9-).

We have learnt many ICD 10 coding tips for pregnancy codes, Z codes, neoplasm, injury etc. But, coding for alcohol use, abuse and dependence have separate guidelines.

Alcohol abuse is defined as excess consumption of alcohol beyond moderate use and on a regular basis with resultant problems. Persons who are alcohol abusers are not physically dependent on alcohol. 

Alcohol abuse is coded in the F10.1 subcategory in ICD-10-CM, with additional characters to represent associated disorders. For example, F10.18 is for alcohol abuse with other alcohol-induced disorders and is further subdivided as follows:

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Coding guidelines for alcohol use, abuse and dependence

For coding alcohol use, abuse and dependence coders must have to follow separate coding guidelines. Now, in ICD 10 CM codebook there are separate entries for alcohol abuse, alcohol dependence, and new entries for alcohol use disorders. Only one code for use, abuse, or dependence on alcohol can be assigned. Below the coding guidelines to follow to code these terms.

If both use and abuse (mild use disorder) are documented -> Assign only the code for abuse (mild use disorder).

If both abuse (mild use disorder), and dependence (moderate or severe use disorder) are documented ->Assign only the code for dependence (moderate or severe use disorder).

If use, abuse (mild use disorder), and dependence (moderate or severe use disorder) are all documented -> Assign only the code for dependence (moderate or severe use disorder).

If both use and dependence (moderate or severe use disorder) are documented -> Assign only the code for dependence (moderate or severe use disorder).

In other words, code to the highest level of use. Abuse is worse than use; dependence is worse than abuse.

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How to code Alcohol Dependence

Alcohol dependence is a chronic disease that involves a physical dependence on alcohol. Patients who have abstained from drinking and are in remission may suffer relapses. 

Alcohol dependence is coded in the F10.2- subcategory, with additional character(s) for associated disorders. For example, F10.23 is for alcohol dependence with withdrawal and is subdivided as follows:

F10.230 Alcohol dependence with withdrawal, uncomplicated

F10.231 Alcohol dependence with withdrawal, delirium

F10.232 Alcohol dependence with withdrawal, with perceptual disturbance

F10.239 Alcohol dependence with withdrawal, unspecified