Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

Release Notes:
Data Element
Version 2020A

Name:Alcohol or Drug Disorder
Collected For: SUB-03, SUB-04
Definition:Documentation in the medical record that the patient has an alcohol or drug use disorder. This documentation can be in the form of an ICD-9-CM code for alcohol or drug use disorder, or narrative documentation in which the physician or other qualified health professional explicitly documents alcohol or drug use disorder.
Question:Is there documentation in the medical record that the patient has an alcohol or drug use disorder?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation in the medical record that the patient has an alcohol or drug use disorder.

N (No) There is no documentation in the medical record that the patient has an alcohol or drug use disorder, or unable to determine from medical record documentation.
Notes for Abstraction:
  • The abstractor should not try to determine if alcohol or drug abuse exists from documentation of symptoms. The health care provider must document explicity that the patient has an alcohol or drug use disorder.
  • For example, if documentation in the record indicates the patient has drink-seeking or drug seeking behavior or alcohol or drug tolerance, but does not specifically use the terminology "alcohol (or drug) disorder or dependent" or "suspect alcohol dependence", select No.
  • If the specific terms utilized in the inclusion notes below are used, select Yes.
  • If a DSM-IV code for alcohol or drug disorder or dependence is documented, select Yes.
Suggested Data Sources:
  • Consultation notes
  • History and physical
  • Progress notes
  • Coding Records
  • Physician Progress Notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Alcohol dependent/dependence
  • Drug dependent/dependence
  • Appears to have
  • Consider
  • Consistent with (C/W)
  • Diagnostic of
  • Evidence of
  • Indicative of
  • Likely
  • Most likely
  • Probable
  • Representative of
  • Admission for Detoxification
  • Delirium Tremens (DTs)
  • Withdrawl syndrom
  • See Appendix A code Table 13.1 for ICD-9-CM codes for Alcohol Disorders, and Table 13.2 for ICD-9-CM codes for Drug Use Disorders
  • See Appendix A procedure code Table 13.3 for procedures that would be administered to patients with alochol or drug use disorders
  • History of dependence
  • Refer to Appendix D Table 2.6 for Qualifiers and Modifiers

Alcohol or Drug Disorder
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Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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