What is the ICD-10 (International Classification of Diseases, 10th Revision) code for a patient in recovery from alcohol dependence, who has stopped drinking and completed rehab?

ICD-10 Coding for Alcohol Dependence in Sustained Remission

For a patient who has stopped drinking and completed rehab, use F10.21 (Alcohol dependence, in remission) as the appropriate ICD-10 code. 1

Understanding the Coding Framework

The ICD-10 coding system requires you to specify both the diagnosis and the remission status. The complete diagnostic code should reflect:

• F10.21: Alcohol dependence, in remission 1
• This code applies when the patient has completed treatment and is no longer actively drinking 1

Key Coding Requirements

You must document the original severity level in your clinical notes (mild, moderate, or severe based on DSM-5 criteria), even though ICD-10 uses a simplified remission code. 1 The severity classification is:

• Mild: 2-3 DSM-5 criteria met 2
• Moderate: 4-5 DSM-5 criteria met 2
• Severe: 6 or more DSM-5 criteria met 2

Remission Criteria

Sustained remission requires ≥12 months without meeting substance use disorder criteria (except craving may persist). 1 This means:

• The patient has not met DSM-5 alcohol use disorder criteria for at least 12 months 1
• Craving alone does not disqualify remission status, as it can persist long into recovery 1
• Complete abstinence is not required—the focus is on whether the patient meets disorder criteria (substance-related difficulties) 1

If your patient has been abstinent for 3-12 months, use early remission coding instead. 1

Clinical Documentation Best Practices

Always include the remission specifier rather than using historical diagnoses to maintain continuity of care and acknowledge the chronic nature of alcohol use disorders. 1 Your documentation should read:

"Alcohol Use Disorder, [Mild/Moderate/Severe], in Sustained Remission" 1

Add additional specifiers when applicable:

• "In a controlled environment" (if in residential treatment) 1
• "On maintenance therapy" (if receiving medications like naltrexone or acamprosate) 1

Common Coding Pitfalls

Do not code as "history of alcohol dependence" or use Z-codes for personal history. 1 The remission specifier maintains the active diagnosis while acknowledging recovery status, which is critical for:

• Insurance coverage for ongoing addiction services 1
• Monitoring for relapse risk 1
• Continuity of specialized care 1

Do not require complete abstinence for remission coding. 1 The American Psychiatric Association focuses on whether the patient continues to experience substance-related difficulties, not solely on abstinence. 1

Supporting the Diagnosis

While not required for coding, consider documenting screening tools used to establish the original diagnosis and monitor recovery:

• AUDIT score (Alcohol Use Disorders Identification Test): Score ≥8 indicates harmful/hazardous drinking 2
• CAGE questionnaire: ≥2 positive responses suggest alcohol use disorder 2

The DSM-5 criteria include 11 diagnostic criteria encompassing tolerance, withdrawal, craving, loss of control, continued use despite consequences, and impairment in social/occupational functioning. 2