Created Mar 2011
Reviewed Dec 2019
Following a road traffic accident patient is initially assessed at Hospital A and is noted to have a Blood Alcohol Level 54 mmol/l. After transfer to Hospital B the Blood Alcohol Level is now 20 mmol/l.
Under the criteria of ACS 0503 Drug, Alcohol and Tobacco Use Disorders – Evidence of Alcohol Involvement Determined by Blood Alcohol Level and Intoxication and ACS 0002 Additional Diagnoses, the Blood Alcohol Level needs to be coded.
Which level should be used to assign the Blood Alcohol Level code?
Should the clinical notes/results from Hospital A be used to code from when coding Hospital B?
Firstly, before the Blood Alcohol Level code (Y90.-) can be assigned the documentation in the clinical record needs to support the code assignment for alcohol intoxication (F10.0), harmful use (F10.1) or dependence syndrome (F10.2) or alcohol poisoning (T51.0) as per ACS 0503 Drug, Alcohol and Tobacco Use Disorders – Evidence of Alcohol Involvement Determined by Blood Alcohol Level and Intoxication.
Once the appropriate alcohol code (F10.- or T51.0) has been determined the clinical coder would then look for documentation of the Blood Alcohol Level.
If the Blood Alcohol Level is documented in the current episode of care and is confirmed by the laboratory result, then the appropriate Blood Alcohol Level code (Y90.-) is to be assigned.
In this case the Blood Alcohol Level at Hospital B was 20mmol/l, therefore, the code Y90.4 Blood alcohol level of 80–99 mg/100 ml is to be assigned.
Clinical coders should only use the documentation/results pertinent to the current episode of care. It would not be acceptable to use the results of the Blood Alcohol Level from Hospital A.
The Blood Alcohol Level will be captured in the coding (as per the criteria of ACS 0503 Drug, Alcohol and Tobacco Use Disorders) at Hospital A if the event meets the NMDS three hour admission rule.