Question

The provider documents that a patient has "ETOH dependence, hasn't had a drink in 5 years."

What is the best action for a coder to take?

A. Assign code F10.20
B. Query the provider to determine if reporting the code for remission is appropriate
C. Assign code F10.21
D. Do not assign a code, because the patient does not have a diagnosis

Answer 1

The correct action is to query the provider for more information to determine if the alcohol dependence is in remission, hence making coding adjustments as needed.

Step-by-step explanation:

The best action for a coder to take when faced with the documentation that a patient has "ETOH dependence, hasn't had a drink in 5 years" is B. Query the provider to determine if reporting the code for remission is appropriate. In medical coding, specific ICD-10 codes are used to represent a patient's diagnosis. The code F10.20 stands for Alcohol dependence, uncomplicated, whereas F10.21 represents Alcohol dependence, in remission.

Since the patient has not had a drink in 5 years, the coder should seek further information from the provider to accurately code for the current clinical status of the patient's condition, since it might be in partial or sustained remission, which would modify the coding. It's crucial that coders capture the most accurate clinical picture of a patient's health to ensure proper handling of the patient's medical records, potential treatment, and billing.