Q&A: Documenting intoxication with a blood alcohol level

Q: If the patient comes in with a high blood alcohol level and the provider documents that number in their note, do they also need to specifically write “patient with intoxication?”

A: Unfortunately, the answer to your question is yes. The coder cannot assume based off a lab value that the person is “intoxicated,” the physician must document in the medical record that the person is in fact “intoxicated at the present time” or “with intoxication.” For coding purposes, the code assignment is solely based on physician documentation of intoxication.

When you see a high blood alcohol level, there are a few things to think about in investigating the patient’s medical record. One of the first things is to look for indicators of a substance abuse issue. And, if they do, what is the substance? Is it alcohol, opioids, or maybe some other substance?

Also identify the level of consumption of the substance, do they “use,” “abuse,” or are they “dependent on” the substance? We can capture a CC if the physician documents that the patient is at the level of dependence and going through withdrawal from the substance. This also is solely based on physician documentation.

The next step would be to identify any complications that would be related to the consumption of the substance. With alcoholism, think about complications such as cirrhosis, liver failure, ascites, bleeding, or encephalopathy. These conditions would have to be linked by the provider in such a manner as to show a cause-and-effect relationship. This requires verbiage such as “due to,” “related to,” or “secondary to.” There are numerous combination codes in ICD-10-CM that represent not only the condition such as alcoholism, but also the complication associated with it. The coder would need the appropriate documentation to assign one of these combination codes.

Lastly, keep your eyes open for any procedures (such as esophagogastroduodenoscopy, banding of varices, endoscopic retrograde cholangiopancreatography) that might be done related to the alcoholism and any one of the numerous complications or manifestations caused by it. Not all of the complications or manifestations are what we refer to as “reimbursable” (meaning, they move the MS-DRG assignment from a medical DRG to a surgical DRG), but some of them can lead to a surgical DRG depending on the procedure performed.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.