Last month's column addressed alcohol use disorder (AUD), connecting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), definitions and diagnostic criteria with the 2018 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) documentation and coding requirements.
This month's column will explain alcohol-induced conditions in the context of AUD. Alcohol-induced conditions are complications directly due to AUD. Most of these conditions also occur independently of AUD. ICD-10-CM requires that the clinician specifically document a connection between these conditions and AUD for them to be coded as “alcohol-induced.” DSM-5 diagnostic criteria also require that other causes be ruled out before documenting a condition as an alcohol-induced condition.
DSM-5 lists and defines certain alcohol-induced conditions (Table 1). Most of these are also listed in ICD-10-CM, which provides multiple codes in category F10 that combine AUD and its associated conditions into one code (Table 2) based on the use/abuse/dependence distinction and clinical circumstances. ICD-10-CM uses the term “uncomplicated” to identify AUD without an alcohol-induced condition.
Intoxication (drunkenness) is an alcohol-induced condition defined by DSM-5 as problematic behavior or psychological changes (often seen after more than two drinks) associated with one or more of several symptoms: slurred speech, incoordination, unsteady gait, nystagmus, impaired attention or memory, or altered level of consciousness. ICD-10-CM provides several codes for alcohol intoxication.
These codes apply to any kind of alcohol intoxication, due to ingestion of a beverage or any other method of consumption, since ICD-10-CM defines a “poisoning” as the toxic effect of a nonmedicinal substance or as a therapeutic drug taken improperly.
Intoxication accompanied by delirium is generally consistent with an “acute toxic encephalopathy” due to alcohol. When this is present, both toxic encephalopathy (code G92) and alcohol-induced delirium (sequenced after G92) should be documented and coded, along with the “toxic effect” code, which should be sequenced first. Delirium should be considered a symptom of the underlying medical condition of toxic encephalopathy.
Documentation of just “alcoholic encephalopathy” results in the assignment of code G31.2, which is reserved for nervous system degeneration like alcoholic cerebellar or cerebral degeneration. It represents a chronic, permanent, structural encephalopathy, not an acute, reversible encephalopathic process—hence the need to document an acute toxic encephalopathy resulting from alcohol intoxication.
The key features of alcohol-induced psychoses are delusions and hallucinations, but they must be distinguished from schizophrenia which is not induced by alcohol. However, AUD may precipitate psychotic episodes in patients with underlying schizophrenia.
According to the DSM-5, persistent neurocognitive disorders (“dementia”) that can be due to AUD include “major” amnesic-confabulatory types (e.g., Korsakoff and Wernicke-Korsakoff) and nonamnesic-confabulatory types, which are identified in ICD-10-CM as amnestic and persistent dementia. Major implies significant cognitive decline that interferes with independent function.
Other alcohol-induced disorders commonly occur with AUD: anxiety disorders, mood disorders, sexual dysfunction, and sleep disorders. If a patient has AUD and any of these disorders, it should always be clarified in the record whether the conditions are related.
Anxiety disorders are numerous (e.g., generalized anxiety, several phobias, and panic disorder) and commonly overlap. They share the features of excessive fear and anxiety and related behavioral disturbances. Mood disorders include depression and other related conditions having complex DSM-5 definitions. Sexual dysfunction includes such things as erectile dysfunction, sexual interest/desire disorders, and other significant disturbances in sexual function.
DSM-5 identifies 10 sleep disorders or groups of disorders, some of which may be alcohol-induced, including insomnia, hypersomnia, and circadian rhythm disturbance. Others, like narcolepsy or sleep apnea, are not related to alcohol.
Finally, clinicians may decide that another condition not specifically listed by ICD-10-CM as an AUD is actually caused by alcohol and document it as such.
In summary, proper diagnosis and coding of AUD and alcohol-induced conditions are complex and challenging. The ICD-10-CM code classification in large part follows DSM-5 definitions with highly specific codes that combine the types of AUD and alcohol-induced conditions.
Clinicians must determine whether a patient has mild, moderate, or severe AUD based on the DSM-5 diagnostic criteria, as well as documenting any alcohol-induced conditions. Clarification of whether a particular condition is due to AUD or not is always needed in the medical record.
A general understanding and basic working knowledge of the diagnostic standards and interrelationships of these conditions contributes to the quality of care, precise documentation, and accurate coding.