ICD-10 Coding for History of Alcohol Use(F10.11, Z86.59)
Complete ICD-10-CM coding and documentation guide for History of Alcohol Use. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Alcohol Use
F10-F19Primary Range
Mental and behavioral disorders due to psychoactive substance use
This range includes codes for disorders related to alcohol use, including abuse, dependence, and remission.
Family and personal history of certain conditions
This range includes codes for personal and family history of alcohol use disorders.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F10.11 | Alcohol abuse, in remission | Use when the patient has a history of alcohol abuse and is currently in remission. |
|
| Z86.59 | Personal history of other mental and behavioral disorders | Use when documenting a past history of alcohol use without current treatment or symptoms. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of alcohol use
Essential facts and insights about History of Alcohol Use
Primary ICD-10-CM Codes for history of alcohol use
Decision Criteria
documentation Criteria
- Explicit documentation of 'in remission' status
Applicable To
- Alcohol abuse in sustained remission
Excludes
- Alcohol dependence in remission (F10.21)
Clinical Validation Requirements
- Provider documentation stating 'in remission'
- No current symptoms of abuse
Code-Specific Risks
- Misclassification if 'in remission' is not documented
Coding Notes
- Ensure 'in remission' is clearly documented by the provider.
Z86.59 - Personal history of other mental and behavioral disorders
Use when documenting a past history of alcohol use without current treatment or symptoms.
Applicable To
- Personal history of alcohol abuse
Excludes
- Current alcohol use disorder
Clinical Validation Requirements
- No active treatment or symptoms
- Historical reference only
Coding Notes
Do not use if the patient is currently being treated for alcohol use disorder.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Alcohol Use to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F10.11.
Impact
Clinical: Misrepresentation of patient's current status, Regulatory: Non-compliance with coding standards, Financial: Potential denial of claims
Mitigation Strategy
Review clinical notes for remission documentation, Educate providers on documentation standards
Impact
Reimbursement: Potential for incorrect reimbursement, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Use F10.11 or F10.21 if the patient is in remission.
Impact
Lack of explicit remission documentation can lead to audit issues.
Mitigation Strategy
Ensure all clinical notes include remission status where applicable.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Alcohol Use, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Alcohol Use
Use these documentation templates to ensure complete and accurate documentation for History of Alcohol Use. These templates include all required elements for proper coding and billing.
Primary Care Follow-up
Specialty: Family MedicineRequired Elements
- Patient history of alcohol use
- Current remission status
- DSM-5 criteria met
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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