ICD-10-CM Chapter 12,Z codes

Code Z51.81

Code Z51.81 is used to report encounters for therapeutic drug monitoring. If the drug being monitored is one that the patient has been receiving on a long-term basis, a code from category Z79 should be added. Coding guidelines do not provide a definition or time frame for long-term drug therapy.

Screening Examinations—Categories Z11-Z13

Codes from categories Z11-Z13 are assigned to tests performed to identify a disease or disease precursors for early detection and treatment for those who test positive. Screening is performed on apparently well individuals who present no signs or symptoms relative to the disease. If a screening examination identifies pathology: The code for the reason for the test (namely the screening code from categories Z11-Z13) is assigned as the principal diagnosis or first-listed code. This code is followed by a code for the pathology or condition found during the screening exam.

Problem Codes—Z55-Z65

Codes from categories Z55 through Z65 are used to indicate certain problems that may affect the patient's care or prevent satisfactory compliance with the recommended regimen. Examples of situations that can affect a patient's compliance are housing problems, social maladjustment, and economic or job concerns.

Subcategory Z03.7

Codes from subcategory Z03.7, Encounter for suspected maternal and fetal conditions ruled out, are generally assigned as the principal or first-listed diagnosis. The Z03.7 codes may be listed as secondary codes when there are multiple encounters on the same day and the medical records for the encounters are combined. Use codes from subcategory Z03.7 in very limited circumstances on the maternal record for a suspected maternal or fetal condition that is ruled out during that encounter. If the condition is confirmed, code the condition instead. Do not use Z03.7 codes if an illness or any signs or symptoms related to the suspected condition or problem are present. Instead, code the diagnosis/symptom. Other codes may be used in addition to subcategory Z03.7, but only if they are unrelated to the suspected condition being evaluated.

History, Status, and Problem Codes as Additional Codes

History, status, and problem codes ordinarily cannot be used as the principal diagnosis or reason for encounter. Exceptions: Codes from categories Z85-Z87 (except subcategory Z87.7) Code Z91.81 Codes from categories Z80-Z84 These codes can be used as additional codes for any patient regardless of the reason for the encounter, but they are ordinarily assigned only when the history, status, or problem has some significance for the episode of care.

Genetic Susceptibility to Disease—Category Z15

Genetic susceptibility refers to a genetic predisposition for contracting a disease. It is important to distinguish susceptibility from carrier state. An individual who is a carrier of a disease is able to pass it on to an offspring. Codes from category Z15 should not be used as principal or first-listed codes.

Admission for Observation and Evaluation

A code from categories Z03-Z04 can be assigned only as the principal diagnosis or reason for encounter, never as a secondary diagnosis. A code from categories Z03-Z04 is ordinarily assigned as a solo code, with two exceptions: When a chronic condition requires care or monitoring during the stay, a code for that condition can be assigned as an additional code. When admission is for the purpose of ruling out a serious injury, such as concussion, codes for minor injuries such as abrasions or contusions may be assigned as additional codes. This exception is based on the fact that such minor injuries in themselves would not require hospitalization.

Special Investigations and Examinations— Category Z01

A code from category Z01 Is assigned as the reason for encounter only when no problem, diagnosis, or condition is identified as the reason for the examination. Z01 codes are rarely appropriate for inpatient coding and never assigned as secondary or additional codes.

Codes Representing Patient History, Status, or Problems Categories

Categories Z85-Z92 Indicate personal history of a previous condition. Do not assign if the condition is still present or still under treatment, or if a complication is present. Categories Z80-Z84 Indicate family history. May be assigned when the family history is the reason for examination or treatment. Categories Z88-Z99 Indicate the patient has a continuing condition or health status that may influence care. For example: tracheostomy (Z93.0), colostomy (Z93.3), cardiac pacemaker (Z95.0), or aortocoronary bypass graft (Z95.1).

Category Z79

Category Z79 is used to indicate a patient's continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use. Codes are assigned if the patient is receiving a medication for an extended period. An additional code is assigned for the condition for which the medication is prescribed. Do not assign a Z79 code when the medication is prescribed to treat an acute illness or injury and is being given for a brief period of time (e.g., antibiotics to treat bronchitis). Do not use Z79 codes for detoxification or maintenance programs in patients with drug dependence.

Admission Post Observation

If a patient is admitted after a period in the outpatient observation unit for further evaluation unrelated to surgery, use as the principal diagnosis: The condition that provided the original reason for the outpatient observation. If a patient is admitted to an observation unit for a medical condition, and the medical condition worsens or does not improve, and the patient is admitted, use as the principal diagnosis: The medical condition that led to the hospital admission.

Sequencing of Category Z15 Codes

Patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter: Code the current condition first, followed by the Z15.- code. Patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists: Assign a follow-up code first, followed by the personal history (Z85.- to Z87.-) and genetic susceptibility codes (Z15.-). The purpose of the encounter is genetic counseling associated with procreative management: Assign code Z31.5, Encounter for genetic counseling, first, followed by a code from category Z15. Assign additional codes for any applicable family or personal history.

Preoperative Evaluations

Preoperative evaluations may involve a variety of ancillary tests. Assign one of the following codes with additional codes for the condition for which surgery is planned and for any findings related to the preoperative evaluation: Z01.810 Encounter for preprocedural cardiovascular examination Z01.811 Encounter for preprocedural respiratory examination Z01.812 Encounter for preprocedural laboratory examination Z01.818 Encounter for other preprocedural examination Z01.83 Encounter for blood typing

Routine Health Examinations

Some of the codes for routine health examinations distinguish between "with" and "without" abnormal findings. Code assignment depends on the information that is known at the time the encounter is being coded. If no abnormal findings were identified during the examination but the encounter is being coded before test results are back, it is acceptable to assign the code for "without abnormal findings." When assigning a code for "with abnormal findings," an additional code(s) should be assigned to identify the specific abnormal finding(s). An examination with abnormal findings refers to a condition/ diagnosis that is newly found, or a change in severity of a chronic condition, during a routine physical exam.

Status Codes

Status codes indicate that a patient is a carrier of a disease, has the sequelae or residual of a past disease or condition, or has another factor influencing a person's health status. Z codes indicating status are redundant when the diagnosis code itself indicates that the status exists. The diagnostic statement "status post" most often refers to an earlier surgery, injury, or previous illness and usually has no significance for the episode of care. No code for the condition is assigned in this case. A personal history code can be assigned if desired. History codes vs. status codes: History—Problem no longer exists. Status—Condition is present.

Z Codes as Principal/First-Listed Diagnosis

The guidelines contain a list of Z codes that may only be assigned as the principal/first-listed diagnosis, except: When there are multiple encounters on the same day and the medical records for the encounters are combined, or When there is more than one Z code that meets the definition of principal diagnosis. These codes should not be reported if they do not meet the definition of principal or first-listed diagnosis.