Forum - Questions & Answers
Aug 20th, 2012 - cjones
Substance or alcohol abuse
I have questions regarding abuse for an inpatient hospital. Can substance abuse be coded if the patient has a positive drug screen for an illegal substance even is the physician does not list substance abuse as a diagnosis? Can alcohol abuse be coded if the alcohol level is above the legal limit but the physician does not list alcohol abuse as a diagnosis?
Aug 20th, 2012 - nmaguire 2,606
re: Substance or alcohol abuse
Abuse must be so stated in the medical record. Never assume.