Alcohol Abuse vs. Dependence: Is it Fraudulent to Knowingly Soft-Pedal a Diagnosis?

Do you think a provider would chart heart disease for a patient with – say – hypertrophic cardiomyopathy because it’s a ‘warmer, fuzzier’ diagnosis? Or try to scare a patient with metabolic disorder into losing weight by diagnosing her prematurely with diabetes?  You’re probably shaking your head in disbelief, yet some providers do just this when it comes to charting dependence on a substance, such as alcohol or other drugs. Their ambivalence leads to documentation of ‘use’ or ‘abuse’ as they fear “stigmatizing” the patient with a diagnosis of addiction, and somehow ‘use’ and ‘abuse’ seem less negative.

Clinicians are ethically mandated to use their medical knowledge and judgment to diagnose a patient’s condition and then to chart it completely and accurately.  So if our hypothetical provider charts in this fashion, is he, in a sense, committing fraud?  Fraud has several definitions:  deceit, trickery, sharp practice, or breach of confidence, perpetrated for profit or to gain some unfair or dishonest advantage; any deception, trickery, or humbug.

While soft-pedaling a diagnosis hardly results in profit or gain, it is dishonest, and in keeping with the definition above, deceitful.  It begs the question of where exactly is the line between accurate reality and a little white lie.  Knowingly charting less than accurately is deceptive and fraudulent.

‘Addiction’ (termed substance dependence by the American Psychiatric Association and coded as 303.xx or 304.xx) is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring anytime in the same 12-month period:

• Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or
  • Markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
  • The characteristic withdrawal syndrome for the substance, or
  • The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than intended.
• There is a persistent desire or unsuccessful effort to cut down or control substance use.

Dependencies are no different from diabetes, or any other condition.  We regularly counsel all providers to ensure their documentation and diagnoses reflect the patient’s reality as they perceive it to be, in their medical judgment, and counsel the patient appropriately.

Sources:
DSM-IV-TR Diagnositc Criteria from the American Psychiatric    Association
Coders’ Desk Reference, 2010, published by Ingenix
Dictionary.com, accessed on 9/21/11