Alcohol Abuse vs. Dependence: Is it Fraudulent to Knowingly Soft-Pedal a Diagnosis? Print
Written by M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC   
Sunday, 03 June 2012 00:00

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.

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About the authors:  M. Alexandra Johnson, FACHE and Wilma N. Torres, CPC are principals at Coleman Consulting Group. The firm's services include:

-Risk Adjusted Reimbursement (MRA)             
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-ICD-10-CM Consulting & Training                   
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-Credentialing & Contracting

For additional information about the firm or to request a complimentary no-obligation consultation, please call 954.578.3331 or email

Last Updated on Monday, 04 June 2012 08:51