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Question: A patient with a history of moderate alcohol dependence presented for a follow-up visit to the gastroenterologist to evaluate the status of the patient鈥檚 chronic stomach ulcer with perforation and hemorrhage. After reviewing the patient鈥檚 history and performing a physical examination, the physician collected a blood sample and ordered an abdominal X-ray to visualize the ulcer. An in-house radiologist captured the X-rays.

The gastroenterologist documented no changes to the patient鈥檚 condition. What diagnosis codes do I need to report for the encounter?

Michigan Subscriber

Answer: You鈥檒l assign K25.6 (Chronic or unspecified gastric ulcer with both hemorrhage and perforation) to report the patient鈥檚 ulcer with hemorrhage and perforation and use F10.20 (Alcohol dependence, uncomplicated) to report the patient鈥檚 moderate alcohol dependence.

Locating the correct diagnosis code for the patient鈥檚 chronic ulcer with hemorrhage and perforation requires you to follow several indentations in the ICD-10-CM Alphabetic Index. Look for this pathway: Ulcer > stomach > with > hemorrhage > and perforation to land at K25.6, which you鈥檒l verify in the Tabular List.

Parent code K25.- (Gastric ulcer) lists a use additional code note instructing you to identify the patient鈥檚 alcohol abuse and dependence with F10.- (Alcohol related disorders), if the information is documented. In your situation, the patient has a history of moderate alcohol dependence, which is covered by F10.20, as the additional condition 鈥渁lcohol use disorder, moderate鈥� is listed under the code.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC