Ask a Rev Cycle Expert: Blood Alcohol Level Coding?
Can a blood alcohol level be coded from a lab report or nursing note?
The blood alcohol level may not be coded from a lab report. An update to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Guideline for 2022 states that blood alcohol levels may be coded when recorded by clinicians other than the patient’s provider, which may include nursing notes. “Clinicians” in this context are defined as, “healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.”
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