Alcohol Use Disorder ICD-10-CM codes

Category F10 is divided by pattern: F10.1- alcohol abuse, F10.2- alcohol dependence, and F10.9- alcohol use, unspecified. The index maps DSM-5 alcohol use disorder by severity: mild goes to abuse (F10.10) and moderate or severe goes to dependence (F10.20). Alcohol use disorder documented without a severity has no direct index entry, so query for severity rather than defaulting. Alcohol use documented as relevant to the encounter with no disorder diagnosed is F10.90.

The official guidelines set a hierarchy when more than one pattern is documented for the same substance: use and abuse together are coded as abuse; abuse and dependence as dependence; use, abuse, and dependence as dependence. Only one code from F10 for the pattern is assigned.

The fifth and sixth characters describe complications: 0 uncomplicated, 1 in remission (only when the provider documents remission), 2- intoxication, 3- withdrawal (F10.230 uncomplicated, F10.231 with delirium, F10.232 with perceptual disturbance), 4 alcohol-induced mood disorder, 5- alcohol-induced psychotic disorder, and 8- other induced disorders such as sleep disorder (F10.282). Withdrawal codes are available at all three levels (F10.13-, F10.23-, F10.93-), so withdrawal in a patient documented with abuse is F10.130 to F10.139 rather than a dependence code.

Add Y90.- for a documented blood alcohol level when it is relevant. Alcoholic polyneuropathy is G62.1 with the F10 code as an additional code. Counseling encounters use Z71.41 for the patient and Z71.42 for a family member. Do not assign an F10 code for a history of alcohol dependence in sustained remission unless the provider documents remission, in which case F10.21 applies.