RHIT: ICD-10-CM Guidelines: Chapter 21 - Z codes

Z37, outcome of delivery

Included on maternal delivery records Always a secondary code

Codes from category Z03.7, encounter for suspected maternal and fetal conditions not for use

When an illness or any signs/symptoms related to the suspected condition or problem are present. Instead you should use the diagnosis/symptom code

What status codes should not be used with

diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code

Prophylactic organ removal

Code first encounter for prophylactic surgery followed by appropriate code(s) to identify the associated risk factor (genetic susceptibility or family history)

Condition discovered during screening

Condition may be assigned as additional diagnosis

Z codes and procedure

Corresponding procedure code must accompany

What is to be used to determine the weeks of gestation for inpatient admissions that encompass more than one gestational week

Date of the admission

Sequencing of multiple aftercare codes

Depends on circumstances of encounter

Should a condition be found to have recurred on the follow-up visit

Diagnosis code used in place of follow-up code

Personal history

Do not exist, no longer receiving treatment but has potential for recurrence

Follow-up code uses

Explains continuing surveillance following completed treatment of a disease, condition, or injury Implies condition is fully treated and no longer exists

Z51.0, Encounter for antineoplastic radiation therapy

First listed followed by diagnosis code when a patient's encounter is solely to receive radiation therapy

Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy

First listed followed by diagnosis code when a patient's encounter is solely to receive therapy

Aftercare code sequencing

First listed or as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable

If the purpose of the encounter is genetic counseling associated with procreative management,

First-listed code should be Z31.5, Encounter for genetic counseling, followed by a code from Z15 with additional codes for any applicable family or personal history

If the patient is being seen for follow-up after completed treatment for a condition and they are genetic susceptible and the condition no longer exists

Follow-up code should be sequenced first followed by the appropriate personal history and genetic susceptibility codes

Follow-up codes may be used in conjunction with ___.

History codes with follow-up sequenced first

Z34, Encounter for supervision of normal pregnancy

Always first-listed and not used with any other OB codes

Encounters for weaning from a mechanical ventilator

Assign a code from J96.1, Chronic respiratory failure, followed by Z99.11, Dependence on respiratory [ventilator] status

Aftercare of injury

Assign the acute injury code with the appropriate 7th character for subsequent encounter

Nonspecific Z codes in outpatient setting

Limited to instances when there is no further documentation to permit more precise coding

Who Z52, Donors of organs and tissues is for

Living donors, not for self or cadaveric donations

For encounters for suspected fetal condition that are inconclusive following testing and evaluation

Use appropriate O code

Category Z20, contact/exposure

Used for patients who do not show any sign/symptom of a disease but are suspected to have been exposed to it

Z23, inoculations and vaccines

Used with procedure codes May be a secondary code if inoculation is given as a routine part of preventive health care

Observation codes uses

Very limited circumstances when a person is being observed for a suspected condition that is ruled out

Codes from category Z03.7, encounter for suspected maternal and fetal conditions ruled out uses

Very limited on a maternal record when an encounter is for a suspected maternal or fetal condition that is ruled out during that encounter Not used when condition confirmed (instead use condition code)

Nonspecific Z codes in inpatient setting

Very little use

Aftercare visit codes uses (encounters)

When initial treatment of a disease has been performed and the patient requires continued care during healing or recovery phase or for the long-term consequences of the disease

During a routine exam, a diagnosis or condition is discovered

Z code encounter followed by additional code for diagnosis

Personal history can be used in conjunction with __.

follow-up codes

When not to use observation codes

If an injury or illness or any signs or symptoms related to the suspected condition are present. In these cases the diagnosis/symptom code is used with the corresponding external cause code.

When encounters for exams should not be used

If the exam is for diagnosis of a suspected condition

When pre-existing, chronic conditions, and history codes can be included with z code for routine and administrative examination

If the examination is for administrative purposes and not focused on any particular condition

When Z40, Encounter for prophylactic surgery should not be assigned

If the patient is having organ removal for treatment of a malignancy

Z77

Indicates contact with and suspected exposures hazardous to health

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 Does not have disease and not at risk for developing disease

Genetic susceptibility, Z15

Indicates that a person has a gene that increases the risk of that person developing the disease Not used as principal/first-listed

Contact/exposure codes

May be used as a first-listed code to explain an encounter for testing or as a secondary code to identify a potential risk

Codes from category Z03.7, encounter for suspected maternal and fetal conditions ruled out sequencing

May be used as a first-listed or as an additional code assignment

Additional codes with category Z03.7, encounter for suspected maternal and fetal conditions

May be used only if they are unrelated to the suspected condition being evaluated

Z98.85, Transplanted organ removal status

Not applied during actual removal

Z78.1, Physical restraint status

Not to be used if patient is temporarily restrained during a procedure

category Z03.7, encounter for suspected maternal and fetal conditions and encounters for antenatal screening of mother

Not used together

Observation code sequencing

PDX Additional codes may be used only if they are unrelated to the suspected condition being observed

If the patient has the condition to which he/she is genetic susceptible and that condition is the reason for the encounter

Sequence the code for the current condition first

If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease

Prophylactic surgery encounter Code for malignancy should also be assigned

Screening code not necessary if ___.

Screening is inherent to a routine examination

Z33.1, Pregnant state, incidental

Secondary code

Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission

Secondary code Applies even if they are still receiving treatment Condition for which required treatment sequenced first

Z16, Resistance to antimicrobial drugs

Sequence infection code first

Screening may be first-listed if ___.

if the reason for the visit is for the screening exam

Aftercare Z code should not be used __.

if treatment is directed at a current, acute disease. Instead, the diagnosis code should be used. aftercare of injuries

Family history codes can be used in conjunction with ___.

screening codes