HCC Coding: Identifying and Correctly Documenting Alcohol Use Disorders

Identifying and Correctly Documenting Alcohol Use Disorders

The COVID-19 Pandemic has significantly changed American life, including the use of alcoholic beverages. It is fact that alcohol is often used as an attempt to cope with stress during the confinement of the lockdowns. Stressors may include a change in work schedules, kids’ educational routines, and financial strains. The respected medical journal JAMA, among other sources, has documented the increase in alcohol use.

Clinically identifying an alcohol problem is challenging. Taking time to address and then accurately document the problem adds additional obstacles for healthcare providers.

The following clinical scenario may be of value:

Mr. H, a 58-year-old male, presents to the primary care provider’s office with a chief complaint of anxiety and shortness of breath. After interviewing this established patient, the provider begins to obtain a clearer picture of the patient’s alcohol use.  During the recent COVID-19 pandemic, Mr. H has seen the decline of his small private business. He admits to gradually increasing his drinking during the lockdown due to financial stress.

Upon further questioning, the provider learns that the patient has tried to stop drinking but cannot and has had several hangovers. The patient admits that his family members have recently spoken to him about his drinking. Despite having increased anxiety, Mr. H has found himself drinking despite knowing it is bad for him. Additionally, he confirms that his relationship with his wife has become more contentious. He denies withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure.  

Based upon the DSM-5 criteria, the patient appears to have a diagnosis of Alcohol Use Disorder (Mild) (ICD-10 code F10.10). 

If the patient returns in 6 weeks, and his alcohol use has increased, rather than subsided or decreased, the patient may qualify for the diagnosis of Moderate Alcohol Use Disorder/ Alcoholism, HCC code F10.20 .  This diagnosis puts the patient at increased risk for comorbidities, including mental health problems, heart disease, liver disease, pancreatic inflammation, and others. 

The key objective for the provider is to determine the degree to which alcohol use is impacting the patient’s life and health. The DSM-5 criteria are the gold standard for identifying the patient’s degree of impairment.

When documenting Alcohol Use Disorders, it is important to document the severity of illness. The definition of this disorder is a problematic pattern of alcohol use with clinical significance, as manifested by two or more of the following symptoms over a 12-month period of time (paraphrased):

  • Excessive time spent in activities necessary to obtain or use alcohol or recover from its use
  • Recurrent use causing failure to meet obligations at home, work, or school
  • Giving up extracurricular activities because of alcohol use
  • Drinking more than one intended
  • Spending more time drinking
  • Inability to decrease or stop drinking alcohol
  • Continued use of alcohol despite knowing it is creating psychological and/or physical harm to self
  • Craving alcoholic beverages
  • Using alcohol when it is physically hazardous
  • Continued alcohol use despite interpersonal and social problems associated with use
  • Tolerance (need for greater volumes to achieve the previous effect)
  • Withdrawal (trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure)

Mild: the presence of two to three symptoms from the DSM-5 criteria

Moderate: the presence of four to five symptoms from the DSM-5 criteria

Severe: the presence of six or more symptoms from the DSM-5 criteria

It is also important to document any associated symptoms (anxiety, dementia, sleep disorder, or other conditions) and conduct a thorough physical exam. If applicable, laboratory studies may be indicated. 

Alcohol misuse screenings & counseling:

Medicare Part B covers one alcohol misuse screening per year for adults who use alcohol, but who do not meet the medical criteria for alcohol dependency. If the primary care provider determines that the Medicare beneficiary is misusing alcohol, the patient may receive up to four brief face-to-face counseling sessions each year (if the patient is competent and alert during counseling).

A psychiatric referral is beneficial for guidance in managing a patient’s comorbid mental health conditions and obtaining expert advice on treating an alcohol use disorder with pharmaceutical treatments. 


Optum 2019-2020 Risk Adjustment Documentation, Coding and Quality Toolbook

2020 Outpatient SDI Pocket Guide third edition, Pinson & Tang

National Institute on Alcohol Abuse and Alcoholism

About the Author

Barbara Lennon, MD

Barbara Lennon, MD

Clinical Documentation Specialist