ICD-10 Coding for History of Alcohol Abuse(F10.11, Z81.1)
Complete ICD-10-CM coding and documentation guide for History of Alcohol Abuse. 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 Abuse
F10-F19Primary Range
Mental and behavioral disorders due to psychoactive substance use
This range includes codes for disorders related to alcohol use, including remission.
Family and personal history of certain conditions
This range includes codes for family and personal history of mental and behavioral 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 documented history of alcohol abuse and is currently in remission. |
|
| Z81.1 | Family history of alcohol abuse | Use when documenting a family history of alcohol abuse that affects patient management. |
|
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 abuse
Essential facts and insights about History of Alcohol Abuse
Primary ICD-10-CM Codes for history of alcohol abuse
Decision Criteria
documentation Criteria
- Explicit documentation of 'in remission' is required.
Applicable To
- Alcohol abuse in sustained remission
Excludes
- Current alcohol abuse (F10.10)
Clinical Validation Requirements
- Provider documentation of 'in remission'
- DSM-5 criteria for remission
- Objective findings such as negative alcohol biomarkers
Code-Specific Risks
- Misinterpreting 'history of' as 'in remission'
Coding Notes
- Ensure remission status is explicitly documented by the provider.
Z81.1 - Family history of alcohol abuse
Use when documenting a family history of alcohol abuse that affects patient management.
Excludes
- Personal history of alcohol abuse (F10.11)
Clinical Validation Requirements
- Documentation of family history impacting patient care
Coding Notes
Do not use as a principal diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Family history of alcohol abuse
Z81.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Alcohol Abuse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F10.11.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential claim rejections.
Mitigation Strategy
Educate providers on remission documentation, Use templates to guide documentation
Impact
Reimbursement: May result in claim denial if used as principal diagnosis., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate representation of patient's primary condition.
Mitigation Strategy
Use Z81.1 only as a secondary code to indicate family history.
Impact
Lack of explicit remission documentation can trigger audits.
Mitigation Strategy
Implement documentation checks for remission status.
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 Abuse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Alcohol Abuse
Use these documentation templates to ensure complete and accurate documentation for History of Alcohol Abuse. These templates include all required elements for proper coding and billing.
Primary Care Follow-up
Specialty: Family MedicineRequired Elements
- Remission status
- Last alcohol use date
- Current treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for History of Alcohol Abuse? Ask your questions below.