Quick reference
- When to use
- Use F10.20 when the client meets criteria for Alcohol Use Disorder, Moderate. Determine severity by symptom count: mild (2-3), moderate (4-5), severe (6+). Specify current status: in early remission, in sustained remission, or on maintenance therapy.
- Duration
- Early remission: 3-12 months without criteria met (except craving). Sustained remission: 12+ months. On maintenance therapy: receiving agonist medication. Tolerance/withdrawal don't count if on prescribed medication.
- Session codes
- Pair with CPT 90834/90837 for therapy. SBIRT: 99408/99409. Medication management: 99213/99214. Group therapy: 90853. Use 96127 for AUDIT/DAST screening. MAT visits may use specific E/M codes.
- Key indicators
- Impaired control over substance use • Social impairment • Risky use • Pharmacological indicators (tolerance, withdrawal) • Craving • Continued use despite problems • Giving up activities
What F10.20 represents
Moderate Alcohol Use Disorder indicates a problematic pattern of alcohol use with 4-5 symptoms present. This represents a significant substance use issue that requires clinical intervention.
Key diagnostic criteria
4-5 of the following within a 12-month period:
- Alcohol taken in larger amounts/longer than intended
- Persistent desire or unsuccessful efforts to cut down
- Great deal of time spent obtaining, using, or recovering
- Craving
- Failure to fulfill major role obligations
- Continued use despite social/interpersonal problems
- Important activities given up or reduced
- Use in physically hazardous situations
- Continued use despite physical/psychological problems
- Tolerance
- Withdrawal
Documentation essentials
Document specific criteria met, quantity/frequency of use, and functional impact. Use AUDIT or CAGE screening tools.
Differential diagnosis
Distinguish from mild (2-3 criteria) and severe (6+ criteria) AUD. Rule out other substance use.
Treatment planning
Motivational interviewing, CBT, 12-step facilitation, naltrexone or acamprosate, group therapy.
Insurance & billing
Well-accepted code. Document severity level clearly.
Updates & changes
DSM-5 combined abuse and dependence into single AUD spectrum with severity levels.
Documentation pitfalls
Specify severity correctly based on symptom count. Document remission when applicable.
References
- American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).