Intro to Medical Coding Chapter 3

Z20:

Contact with and (suspected) exposure to communicable diseases

Z23:

Encounter for immunization (inoculations and vaccinations) (It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code _______ may be used as a secondary code if the inoculation is given as a routine part of the preventive health care, such as well-baby visit.)

Z14:

Genetic carrier (Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease.)

Categories of Z codes:

1.) Contact/Exposure 2.) Inoculations and vaccinations 3.) Status

Z88:

Allergy status to drugs, medicaments and biological substances (Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status)

Z21:

Asymptomatic human immunodeficiency virus (HIV) infection status (This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease.)

Z68:

Body mass index (BMI) (BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy.)

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

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For an outpatient service, a history code (Z80-Z87) may be assigned as a secondary code if the historical condition or family history has an impact on the current care or has an influence on the treatment.

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For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.

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For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

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For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/ visit.

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For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.

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For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis.

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For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category 009, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis.

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If the pre- and postoperative diagnoses are different, the postoperative diagnosis should be reported.

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In the inpatient hospital setting, probable, suspected, and rule-out diagnoses can be reported by the facility as though the condition exists.

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In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.

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Section IV Guidelines for coding and reporting have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.

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Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment.

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The External Cause Index classifies environmental events (tornadoes, floods), circumstances, and other conditions as the cause of injury and other adverse effects alphabetically. Rather these codes are reported to clarify injury or adverse effects.

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The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.

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The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

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The term "primary diagnosis" is the same as the first-listed diagnosis.

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The two categories of Z codes that report observation are Z03 and Z04. These observation codes are reported only as the first-listed diagnosis for medical observation for suspected conditions and conditions ruled out. Other codes may be reported in addition to the observation codes but only when that condition or conditions are unrelated to the reason for the observation.

True

Therapeutic Services Only sequence first the diagnosis, condition, problem, or other reason for encounter in the medical record to be chiefly responsible for the outpatient services provided during the encounter.

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When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis.

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When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.

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When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.

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When an encounter is for a therapeutic service, the first-listed code is the diagnosis, condition, or problem shown to be chiefly responsible for the therapeutic service.

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When an external cause code is reported, it is reported in addition to an injury code from the Tabular List of the I-10. The external cause codes are codes that provide greater detail.

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Z Codes are located at the end of the tabular.

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Z codes can be used in the outpatient setting.

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Z codes may be assigned as first-listed or a secondary diagnosis.

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Z79:

Long-term (current) drug therapy (Codes from this category indicate a patient's continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis).

Coexisting Conditions are coded at the time of the encounter when they require or affect patient care treatment or management.

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Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk.

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Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," "compatible with." "consistent with," or "working diagnosis" ' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

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External Cause Codes are never reported as the first-listed diagnosis.

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A Status Code is assigned to indicate that a patient has a sequele or residual of a past disease or condition or is a current carrier of a disease.

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A patient is admitted to an observation unit for a medical condition that has worsened and is then admitted as an inpatient to the same hospital for the same medical condition. The primary diagnosis would be the medical condition that led to the admission.

True

A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

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A status code is distinct from a history code. The history code indicates that the patient no longer has the condition.

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A status code is informative, because the status may affect the course of treatment and its outcome.

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A status code should not be used with a diagnosis code from one the body system chapters, if the diagnosis code includes the information provided by the status code.

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Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

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Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment.

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Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.

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Code all the documented conditions that coexist at the time of an encounter/visit and require or affect patient care, treatment, or management.

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Codes from category 009, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code 080, Encounter for full-term uncomplicated delivery.

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