Find information on documenting and coding a personal history of alcohol abuse for healthcare purposes. Learn about clinical terminology, ICD-10 codes (F10, Z71.4), diagnostic criteria, and best practices for accurate medical record keeping related to past alcohol dependence, alcohol use disorder, and substance abuse history. This resource offers guidance for clinicians, physicians, and medical coders seeking accurate information on personal history of alcohol abuse documentation and coding.
Also known as
Alcohol abuse, in remission
Personal history of alcohol abuse, currently not drinking.
Personal history of alcohol abuse
Past alcohol abuse, not currently active.
Personal history of alcohol dependence
History of alcohol dependence, may or may not be currently in remission.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient currently abusing alcohol?
Yes
Do NOT code personal history. Code the active alcohol abuse (e.g., F10.10, F10.20).
No
Is there documented past alcohol abuse?
When to use each related code
| Description |
|---|
| Personal history of harmful alcohol use |
| Alcohol use disorder, mild |
| Alcohol use disorder, moderate |
Coding F10.90 without specificity when documentation supports a more detailed alcohol-related diagnosis (e.g., dependence, intoxication) leads to inaccurate severity reflection.
Lack of clear documentation of active, in remission, or resolved alcohol abuse status impacts coding accuracy (e.g., using F10.2x vs. Z86.4) and quality reporting.
Incorrectly coding alcohol abuse as the cause of other conditions without documented support leads to inaccurate risk adjustment and inflated reimbursement.
Patient presents with a personal history of alcohol abuse (alcohol use disorder, AUD), substantiated by self-report and corroborating information from family. The patient acknowledges a pattern of alcohol consumption exceeding recommended guidelines, resulting in negative consequences impacting social, occupational, and interpersonal functioning. Symptoms consistent with alcohol dependence, such as increased tolerance, withdrawal symptoms upon cessation, and unsuccessful attempts to reduce or control alcohol intake, were reported. The patient denies current alcohol use and reports a period of sobriety for [duration]. However, given the past history of alcohol abuse, relapse prevention strategies and support systems will be essential components of the treatment plan. Diagnostic criteria for alcohol use disorder as per the DSM-5 are met. Assessment for co-occurring mental health disorders, including anxiety and depression, will be conducted. The patient will be provided with information regarding community resources, including Alcoholics Anonymous and SMART Recovery, and will be encouraged to engage in individual or group therapy for substance abuse counseling. Referral to addiction medicine specialist will be considered if indicated. Current treatment plan focuses on maintaining sobriety, developing coping mechanisms, and addressing underlying factors contributing to alcohol abuse. ICD-10 code F10.21 (Personal history of alcohol abuse) is assigned. Continued monitoring and support will be provided to facilitate long-term recovery and prevent relapse.