Coding Guidelines for Alcohol Use Disorder in Sustained Remission (2 Years)
For a patient with alcohol use disorder who has been in sustained remission for 2 years, you should code the diagnosis as Alcohol Use Disorder, [severity], in Sustained Remission, as sustained remission is defined as ≥12 months without meeting DSM-5 substance use disorder criteria (except craving). 1
DSM-5 Remission Specifiers
The DSM-5 simplified remission coding by eliminating partial remission categories and establishing two clear timeframes 1:
- Early Remission: ≥3 months but <12 months without meeting DSM-5 substance use disorder criteria (except craving) 1
- Sustained Remission: ≥12 months without meeting DSM-5 substance use disorder criteria (except craving) 1
Since your patient has been in remission for 2 years, this clearly meets the sustained remission threshold. 1
Key Coding Considerations
Craving Exception
The remission criteria specifically allow for the presence of craving, as this symptom can persist long into remission without indicating active disorder 1. This means a patient can still be coded as "in sustained remission" even if they experience occasional cravings for alcohol.
Severity Specification
You must include the original severity level in your diagnosis code 1:
- Mild: 2-3 criteria met
- Moderate: 4-5 criteria met
- Severe: 6 or more criteria met
The complete diagnosis would read: "Alcohol Use Disorder, [Mild/Moderate/Severe], in Sustained Remission" 1
Additional Specifiers
If applicable, you may also add 1:
- "In a controlled environment" - if the patient is in a setting where access to alcohol is restricted
- "On maintenance therapy" - if the patient is receiving medications such as naltrexone, acamprosate, or disulfiram 1
Common Pitfalls to Avoid
Do not code this as "history of" alcohol use disorder - the DSM-5 uses specific remission specifiers rather than historical diagnoses, which maintains continuity of care and acknowledges the chronic nature of substance use disorders 1. The sustained remission specifier is the appropriate code, not a past medical history notation.
Do not require complete abstinence for remission coding - the DSM-5 criteria focus on whether the patient meets disorder criteria (substance-related difficulties), not on the extent of use itself 1. However, in clinical practice, sustained remission typically involves abstinence or very minimal use without meeting any other criteria.