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Ask a Rev Cycle Expert: Blood Alcohol Level Coding?

Question:

Can a blood alcohol level be coded from a lab report or nursing note?

Answer:

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.”

Disclaimer: This information was current at the time of its publishing and is designed to provide accurate information in regard to the subject matter covered. Vitalware does not accept any responsibility or liability with regard to any errors, omissions, misuses, or misinterpretation by the reader. It is not intended to take the place of either the written policies or regulations. We encourage you to review the specific regulations and other interpretive materials as necessary. All CPT® codes are trademarked by the American Medical Association (AMA) and all revenue codes are copyrighted by the American Hospital Association (AHA).