AHA Coding Clinic® for ICD-9 - 2010 Issue 1; Clarifications

5th Digits for Pattern of Use for Alcohol and Drug Abuse/Dependence

Please provide clarification regarding the fifth digit subclassification for categories 303-305 to indicate the patient’s pattern of drug and alcohol abuse. In Coding Clinic, Second Quarter 1991, page 11, advice was provided to allow facilities to use documentation from “technical and professional personnel other than the attending physician” for the purpose of assigning fifth digits. In addition, examples were given regarding the corresponding fifth digits. We understand that coding should be based on the documentation of a provider as defined in the Official Guidelines for Coding and Reporting—the physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Since technical and professional personnel such as rehabilitation counselors and other professionals are not legally responsible for establishing the patient’s diagnosis, we wonder if their documentation could be used to provide further specificity for the selection of the fifth digits for these codes? ...

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