Q&A: Query for ’tremors’ related to alcoholism for additional specificity

Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?

A: No, tremors in an alcoholic cannot be assumed as DTs. If the provider documents “tremor” without additional specification it defaults to code 781.0, abnormal involuntary movements (tremors, NOS – not otherwise specified). The provider would need to specifically refer to the condition as DTs or they could document “alcohol withdrawal delirium” or “alcoholic delirium,” both of which map to code 291.0, which is a CC. The key word is “delirium” not tremors. The code set can also differentiate between acute and chronic alcoholic delirium (alcohol induced persisting dementia a.k.a. alcoholic dementia), but both are CCs.

Additionally, the documentation would need to be clear that the patient was experiencing DTs rather than preventing DTs. A condition that is being prevented does not qualify as a secondary diagnosis so it would not be appropriate to assign a code based on this documentation. Documentation of alcohol withdrawal (291.81) is also a CC as a secondary diagnosis.

The key here is for the provider to document the patient has alcohol “dependence” rather than alcohol abuse. The code set only recognizes withdrawal as a condition that occurs with dependence of any substance, which is a physiological response to cessation of use of the substance. Therefore, alcohol dependence with withdrawal symptoms also supports use of code 291.81.

Something else you can consider when reviewing an alcoholic case is that these patients usually receive a “banana bag” in the emergency room, which is IV fluids with multi-vitamins including thiamine. If the provider documents “evidence of thiamine deficiency” as a diagnosis associated with the treatment of a “banana bag” (it is appropriate to query when treatment is documented without documentation of the condition being treated), then this maps to a 265.* code.

However, if the “banana bag” is a prophylactic treatment then it would not be appropriate to assign a code. A multiple choice query with prophylactic treatment as an option may be a compliant way to approach such a query. For example:

Dear Dr. Z:

Please provide a diagnosis associated with the administration of an IV “banana bag” in the emergency department on (date/time) for Mr. X who has a history of “alcoholism” in the next 24 hours or next progress note by documenting your response below:

• Evidence of thiamine deficiency due to chronic alcohol use/alcoholism
• Prophylactic treatment of potential thiamine deficiency associated with chronic alcohol use/alcoholism
• Unable to determine
• Other: ______________

And be sure to have the physician provide his/her authentication per your organizational guidelines if documentation occurs on query form.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article originally published on the ACDIS Blog.