Find information on Alcohol Use Disorder, Moderate Dependence, including clinical documentation and medical coding for Moderate Alcohol Use Disorder and Alcohol Abuse, Uncomplicated. Learn about diagnosis criteria, treatment options, and healthcare resources related to moderate alcohol dependence for accurate medical coding and improved patient care. This resource supports healthcare professionals in properly documenting and coding cases of AUD with moderate dependence.
Also known as
Alcohol use disorder, moderate
Moderate alcohol use disorder causing clinically significant impairment or distress.
Alcohol use disorder, mild
Mild alcohol use disorder causing clinically significant impairment or distress.
Alcohol use disorder, unspecified
Alcohol use disorder where the severity is not specified.
Problem related to lifestyle
Problems related to lifestyle choices, including alcohol use.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient's alcohol use disorder moderate?
Yes
Is there physical dependence?
No
Do not code as moderate alcohol use disorder. Review documentation and select appropriate ICD-10-CM code.
When to use each related code
| Description |
|---|
| Moderate alcohol use disorder. |
| Severe alcohol use disorder. |
| Mild alcohol use disorder. |
Coding Alcohol Use Disorder without specifying Mild, Moderate, or Severe dependence risks inaccurate reimbursement and data analysis.
Failing to code co-occurring conditions like anxiety or depression with AUD impacts quality reporting and care planning.
Insufficient documentation supporting Moderate Dependence diagnosis can lead to claim denials and compliance issues.
Q: What are the most effective evidence-based interventions for moderate alcohol use disorder in primary care settings?
A: For patients presenting with moderate alcohol use disorder in a primary care setting, several evidence-based interventions have demonstrated efficacy. Brief interventions, such as the FRAMES model (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy), can be effectively implemented within a routine visit. Motivational interviewing techniques can help explore patient ambivalence and enhance motivation for change. Consider implementing standardized screening tools like the AUDIT-C to identify patients early and tailor interventions accordingly. For patients requiring more intensive treatment, referral to specialized care, including cognitive behavioral therapy (CBT) or mutual support groups like Alcoholics Anonymous, should be considered. Explore how integrating these interventions into your practice can improve patient outcomes. Learn more about tailoring treatment plans based on individual patient needs and preferences.
Q: How can I differentiate between mild, moderate, and severe alcohol use disorder when using the DSM-5 diagnostic criteria in a clinical assessment?
A: The DSM-5 provides specific criteria for differentiating alcohol use disorder severity. Mild AUD is characterized by the presence of 2-3 symptoms, moderate AUD by 4-5 symptoms, and severe AUD by 6 or more symptoms. These symptoms encompass impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal). Clinicians should carefully assess the number and severity of symptoms present to accurately determine the level of severity. For example, a patient experiencing strong cravings, neglecting major roles due to alcohol use, and continuing to drink despite recurrent interpersonal problems likely meets the criteria for moderate AUD. Consider implementing a structured clinical interview to systematically assess each criterion and avoid diagnostic errors. Explore the DSM-5 criteria in detail to ensure accurate diagnosis and facilitate appropriate treatment planning.
Patient presents with moderate alcohol use disorder (AUD), fulfilling DSM-5 diagnostic criteria for alcohol dependence. The patient reports a problematic pattern of alcohol use leading to clinically significant impairment or distress, manifested by at least four of the following symptoms within a 12-month period: increased alcohol tolerance, withdrawal symptoms upon cessation or reduction of intake, alcohol consumption in larger amounts or over a longer period than intended, persistent desire or unsuccessful efforts to cut down or control alcohol use, significant time spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects, craving or a strong desire or urge to use alcohol, and continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. Patient acknowledges difficulty controlling alcohol consumption despite awareness of negative consequences related to health, work, and relationships. No evidence of severe withdrawal symptoms requiring medical detoxification was noted at this time. The patient's current alcohol use is impacting their daily functioning and overall well-being. Differential diagnoses considered included other substance use disorders and mood disorders. Assessment suggests the need for alcohol addiction treatment, including individual andor group therapy focusing on relapse prevention strategies, cognitive behavioral therapy (CBT), and motivational interviewing. A referral to a certified alcohol and drug counselor is recommended. Patient education regarding the risks and consequences of alcohol use disorder, available treatment options, and support resources was provided. Follow-up appointment scheduled to monitor progress and adjust treatment plan as needed. ICD-10 code F10.20 will be used for billing purposes. This diagnosis impacts medical decision-making regarding medication management and overall healthcare planning.