Alcohol Use Disorder Documentation Guide
Problematic pattern of alcohol use causing significant impairment or distress.
ICD-10 Codes: F10.10, F10.11, F10.20, F10.21, F10.230, F10.231, F10.239, F10.99
Common Symptoms
- Tolerance
- Withdrawal symptoms
- Craving
- Inability to cut down
- Continued use despite consequences
Key Documentation Elements
- Severity level (mild 2-3, moderate 4-5, severe 6+ DSM-5 criteria)
- Current use pattern and last drink
- Withdrawal risk assessment (CIWA-Ar score)
- Medication-assisted treatment (naltrexone, acamprosate, disulfiram)
- Psychosocial interventions and recovery support
Documentation Challenges
- Documenting severity level (mild, moderate, severe per DSM-5)
- Recording CIWA-Ar protocol scoring for withdrawal management
- Capturing medication-assisted treatment details (naltrexone, acamprosate)
- Tracking screening (AUDIT-C) and brief intervention counseling
Billing Considerations
- Use vs dependence coding (F10.1x mild vs F10.2x moderate-severe)
- Withdrawal management (F10.230, F10.231, F10.239) procedure coding
- SBIRT (Screening, Brief Intervention, Referral to Treatment) billing
Frequently Asked Questions
How is alcohol use disorder severity coded?
Mild AUD uses F10.10/F10.11, moderate-severe uses F10.20/F10.21. Withdrawal uses F10.23x codes. Scribeable maps your documented DSM-5 criteria count to the correct severity and complication codes.
How does Scribeable support addiction medicine documentation?
Scribeable captures screening scores, DSM-5 criteria, withdrawal assessments, MAT details, and counseling documentation from your encounter, streamlining substance use disorder management notes.