F10.20 — Alcohol Use Disorder, Moderate

Clinical Description

F10.20 codes alcohol dependence without additional complications (withdrawal, delirium, psychotic disorder, etc.). In DSM-5 terms, moderate alcohol use disorder corresponds to meeting 4-5 of 11 diagnostic criteria. Documentation must specify the pattern and consequences of use.

Key Symptoms to Document

When using F10.20, your documentation should reference these symptoms:

• Alcohol consumed in larger amounts or over longer periods than intended
• Persistent desire or unsuccessful efforts to cut down or control use
• Significant time spent obtaining, using, or recovering from alcohol
• Craving or strong urge to use alcohol
• Continued use despite social or interpersonal problems caused by alcohol
• Tolerance: need for increased amounts or diminished effect with same amount

Common Interventions to Document

Evidence-based interventions typically documented with this diagnosis:

• Motivational Interviewing (MI)
• CBT for substance use disorders
• Medication-assisted treatment (naltrexone, acamprosate, disulfiram)
• 12-step facilitation or mutual-help group referral (AA)
• Relapse prevention planning

CPT Code Pairings

Common CPT codes used when billing with F10.20:

• 90791 — Psychiatric diagnostic evaluation
• 90837 — Individual psychotherapy, 60 minutes
• 90834 — Individual psychotherapy, 45 minutes
• 99214 — Office visit, moderate complexity (medication management)
• 99408 — Alcohol/substance screening and brief intervention (15-30 min)

Documentation Tips

• Document the specific DSM-5 criteria met (4-5 of 11 for moderate severity) with clinical examples.
• Record quantity and frequency of alcohol use (standard drinks per day/week).
• Document consequences: legal, occupational, relational, medical (elevated LFTs, GI problems).
• Assess and document withdrawal risk using CIWA-Ar scale if applicable.
• Screen for and document co-occurring mental health conditions (depression, anxiety, PTSD).

Differential Diagnosis Considerations

When documenting F10.20, consider and rule out:

• Alcohol use disorder, mild (F10.10)
• Alcohol use disorder, severe (F10.20 with additional specifiers)
• Other substance use disorders (F1x.x)
• Bipolar disorder with increased risk-taking (F31.x)
• Major depressive disorder with self-medication pattern (F32.x)

Screening Tools

Standardized measures commonly used with this diagnosis:

• AUDIT (Alcohol Use Disorders Identification Test)
• AUDIT-C (abbreviated 3-item version)
• CAGE Questionnaire
• CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol)
• DAST-10 (for polysubstance screening)