Presence of alcohol in blood, level not specified

This code indicates that alcohol was detected in a patient's blood, but the specific blood alcohol concentration (BAC) or level was not documented. It confirms the presence of alcohol without quantifying the amount.

Use this code when laboratory tests confirm the presence of alcohol in a patient's system, but the medical record does not specify the measured BAC. This is appropriate when the clinical impact of alcohol is noted, but the exact level is not pertinent or available for coding.

• Only use when the documentation explicitly states "alcohol present" without a quantifiable level.
• Avoid using if a specific BAC is documented; instead, use the appropriate Y90.x code for the documented level.
• This code is often used as a secondary code to provide additional context for the patient's condition or injury.