2025 ICD-10-CM code F10.9
Unspecified alcohol use. This code is used when a provider does not specify the type or degree of alcohol use, excluding alcohol abuse or dependence.
Medical necessity is established by the clinical documentation supporting the diagnosis of unspecified alcohol use.This may include evidence of harmful alcohol consumption patterns and associated physical, mental, or social consequences.
Clinicians should assess the patient's alcohol consumption patterns, including frequency, quantity, and any negative consequences. Physical examination and laboratory tests (e.g., blood alcohol and thiamine levels) may be necessary.
- Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
- Mental and behavioral disorders due to psychoactive substance use (F10-F19)
In simple words: This code is used when someone drinks too much alcohol, but the doctor doesn't specify what kind of drinking problem it is.It's not used for alcohol abuse or addiction.
Unspecified alcohol use refers to excessive alcohol consumption where the type or degree of use is not documented, but it does not meet the criteria for alcohol abuse or dependence. Harmful alcohol consumption is defined as more than 14 drinks per week or 4 drinks per occasion for men, and more than 7 drinks per week or 3 drinks per occasion for women and those over 65. Symptoms can include memory loss, poor coordination, anxiety, depression, and behavioral problems.
Example 1: A 30-year-old male presents with anxiety and difficulty sleeping. He admits to drinking several beers most nights to relax but denies dependence or withdrawal symptoms. The physician documents "unspecified alcohol use.", A 45-year-old female is admitted to the hospital after a fall. She has slurred speech and poor coordination. Her blood alcohol level is elevated, but she doesn't meet the criteria for alcohol dependence. The code F10.9 is assigned., A 60-year-old male is brought to the emergency room by his family due to confusion and memory loss.He has a history of heavy alcohol use. Further examination reveals thiamine deficiency. F10.9 and a code for the thiamine deficiency are assigned.
Document the patient's alcohol consumption patterns, including frequency, quantity, and any associated symptoms or consequences. If applicable, document blood alcohol levels and any other relevant laboratory findings.
- Specialties:Internal Medicine, Family Medicine, Psychiatry, Emergency Medicine
- Place of Service:Office, Inpatient Hospital, Emergency Room - Hospital, Outpatient Hospital, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home