ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

Chapter 20

FACTORS INFLUENCING HEALTH AND CONTACT WITH HEALTH CARE SERVICES

Introduction

The codes for factors influencing health and contact with health care services, represent reasons for encounters. These codes are located in Chapter 20 and the initial alpha character is Z so they may be referred to as Z codes. While code descriptions in Chapter 20, such as Z00.110 Health examination of newborn under 8 days old, may appear to be a description of a service or procedure, codes in this chapter are not procedure codes. These codes represent the reason for the encounter, service or visit and the procedure must be reported with the appropriate procedure code. The best way to become familiar with the types of codes that are included in the supplementary section is to review the code blocks in ICD-10-CM. Below is a table outlining the blocks for factors influencing health and contact with health care services.

ICD-10-CM Blocks
Z00-Z13	Persons Encountering Health Services for Examinations
Z14-Z15	Genetic Carrier and Genetic Susceptibility to Disease
Z16	Resistance to Antimicrobial Drugs
Z17	Estrogen Receptor Status
Z18	Retained Foreign Body Fragments
Z20-Z29	Persons With Potential Health Hazards Related to Communicable Diseases
Z30-Z39	Persons Encountering Health Services in Circumstances Related to Reproduction
Z40-Z53	Encounters for Other Specific Health Care
Z55-Z65	Persons Encountering Health Services in Circumstances Related to Socioeconomic and Psychosocial Circumstances
Z66	Do Not Resuscitate Status
Z67	Blood Type
Z68	Body Mass Index [BMI]
Z69-Z76	Persons Encountering Health Services in Other Circumstances
Z77-Z99	Persons With Potential Health Hazards Related to Family and Personal History and Certain Conditions Influencing Health Status

Even a cursory comparison of the blocks in ICD-10-CM, shows a significant reorganization of codes and code categories from historical code systems. Encounters for routine examinations such as general adult medical examination, newborn health examination, routine child health examination, and vision and hearing examinations are all included in the first block of codes in ICD-10-CM.

Coding Note(s)

The coding notes have been revised to illustrate ICD-10-CM codes classified as factors influencing health status and contact with health services. ICD-10-CM chapter level coding notes are discussed here.

Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z-code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as ‘diagnoses’ or ‘problems’. This can arise in two main ways:

•When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive a prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury

•When some circumstance, condition, or problem is present which influences the person’s health status but is not in itself a current illness or injury

Exclusions

There are no chapter level exclusions listed in Chapter 21.

Chapter Guidelines

There are extensive chapter-specific coding guidelines in ICD-10-CM for factors influencing health status and contact with health services. An overview of the ICD-10-CM guidelines is provided here. For the complete guidelines consult the most current ICD-10-CM Official Guidelines for Coding and Reporting for the code set.

Chapter 21 guidelines provide additional information about the use of Z codes for specific types of encounters. Z codes may be used in any healthcare setting and most Z codes may be either a principal/first-listed or secondary code depending on the circumstances of the encounter. Certain Z codes may only be used as a first listed or principal diagnosis while others, such as Z55-Z65, may only be reported as secondary diagnoses. Z codes are not procedure codes. They indicate the reason for the encounter and a corresponding procedure code must accompany a Z-code to describe the service provided or the procedure performed.

Although code assignment is based on documentation by the patient’s provider, there are a few exceptions in reporting Z codes. Codes for reporting social determinants of health found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, may be assigned based on medical record documentation from clinicians involved in the patient’s care who are not the patient’s provider since this information represents social information, and not medical diagnoses. Self-reported documentation by the patient can also be used for assigning social determinant codes, as long as the information is signed-off and incorporated into the health record by a clinician or provider.

Categories of Z codes

The guidelines identify 16 broad categories of Z codes. Each of these broad categories contains categories and subcategories of Z codes for similar types of patient visits/encounters with similar reporting rules. A description of each of the 16 categories and use of the codes in these categories is summarized here. Consult the most current ICD-10-CM Official Guidelines for Coding and Reporting for the complete guidelines for Chapter 21.

Contact/Exposure

There are two types of contact/exposure codes which may be reported as either a first-listed code to explain an encounter for testing, or as a secondary code to identify a potential risk. These two types of codes are found in two categories of contact/exposure Z codes. Category Z20 indicates contact with, and suspected exposure to communicable diseases. These codes are reported for patients who do not show signs or symptoms of a disease but are suspected to have been exposed to it either by a close personal contact with an infected individual or by being in or having been in the area where the disease is epidemic. Category Z77 indicates contact with or suspected exposure to substances that are known to be hazardous to health. Code Z77.22 Exposure to tobacco smoke (second hand smoke) is included in this category.

Inoculations and Vaccinations

There is a single code, Z23 Encounter for immunization, in this category of Z codes. Code Z23 is for encounters for inoculations and vaccinations and indicates that a patient is being seen to receive a prophylactic inoculation against a disease. A procedure code is required to capture the administration of the immunization of vaccination and to identify the specific immunization/vaccination provided. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.

Status

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. Codes for the presence of prosthetic or mechanical devices resulting from past treatment are categorized as status codes. A status code is helpful because the status may affect the course of treatment and its outcome. Status codes should not be confused with history codes which indicate that a patient no longer has the condition. Status codes are not used with diagnosis codes that provide the same information as the status code. For example, code Z94.1 Heart transplant status, should not be used with a code from subcategory T86.2 Complications of heart transplant because codes in subcategory T86.2 already identify the patient as a heart transplant recipient. Status Z codes/categories include:

•Z14 Genetic carrier – Genetic carrier status indicates that a person carries a gene associated with a particular disease, but does not have the disease and is not at risk for developing the disease. Genetic carriers may pass the defective gene to offspring who may develop the disease.

•Z15 Genetic susceptibility to disease – Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.

–Category Z15 codes are not reported as a principal or first-listed diagnosis

–If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition is sequenced first

–If the patient is seen for follow-up after completing treatment for the condition and the condition no longer exists, a follow-up code is sequenced first, followed by the appropriate personal history and genetic susceptibility codes

–If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5 Encounter for procreative genetic counseling should be assigned as the first-listed diagnosis, followed by a code from category Z15. Additional codes should be assigned for any family or personal history

•Z16 Resistance to antimicrobial drugs – This code indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first.

•Z17 Estrogen receptor status

•Z18 Retained foreign body fragments

•Z19 Hormone sensitivity malignancy status

•Z21 Asymptomatic HIV infection status – This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease.

•Z22 Carrier of infectious disease – Carrier status indicates that the person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection.

•Z28.3 Underimmunization status

•Z33.1 Pregnant state, incidental – This code is a secondary code only for use when the pregnancy is in no way complicating the reason for the visit. Otherwise a code from the obstetric chapter is required.

•Z66 Do not resuscitate – This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay.

•Z67 Blood type

•Z68 Body mass index [BMI] – As with all other secondary diagnosis codes, BMI codes should only be assigned when the associated diagnosis (e.g., obesity, overweight) meets the definition of a reportable diagnosis. Do not assign BMI codes during pregnancy.

•Z74.01 Bed confinement status

•Z76.82 Awaiting organ transplant status

•Z78 Other specified health status – Code Z78.1 Physical restraint status may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. Please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure.

•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.

–Assign a code from category 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)

–Do not use these codes for patients who have addictions to drugs

–Do not use these codes for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead

•Z88 Allergy status to drugs, medicaments and biological substances (except Z88.9)

•Z89 Acquired absence of limb

•Z90 Acquired absence of organs, not elsewhere classified

•Z91.0 Allergy status, other than to drugs and biological substances

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

–Assign code Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility

–This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility

–The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first

–Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record

•Z93 Artificial opening status

•Z94 Transplanted organ and tissue status

•Z95 Presence of cardiac and vascular implants and grafts

•Z96 Presence of other functional implants

•Z97 Presence of other devices

•Z98 Other postprocedural states

–Assign code Z98.85 Transplanted organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter

–See section I.C.19 for information on the coding of organ transplant complications

•Z99 Dependence on enabling machines and devices, not elsewhere classified. For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, Chronic respiratory failure, followed by code Z99.11, Dependence on respirator [ventilator] status.

Note: Categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.

History (of)

There are two types of history Z codes, personal and family which are defined as follows:

•Personal history codes – Explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring

–May be used in conjunction with follow-up codes to explain the need for a test or procedure

•Family history codes – For use when a patient has a family member who has had a particular disease that causes the patient to be at higher risk of also contracting the disease

–May be used in conjunction with screening codes to explain the need for a test or procedure

•History codes are also acceptable on any medical record regardless of the reason for the encounter. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered

History Z codes/categories include:

•Z80 Family history of primary malignant neoplasm

•Z81 Family history of mental and behavioral disorders

•Z82 Family history of certain disabilities and chronic diseases (leading to disablement)

•Z83 Family history of other specific disorders

•Z84 Family history of other conditions

•Z85 Personal history of malignant neoplasm

•Z86 Personal history of certain other diseases

•Z87 Personal history of other diseases and conditions

•Z91.4- Personal history of psychological trauma, not elsewhere classified

•Z91.5 Personal history of self-harm

•Z91.81 History of falling

•Z91.82 Personal history of military deployment

•Z92 Personal history of medical treatment (except Z92.0 Personal history of contraception and Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility.

Screening

Screening is testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g. screening mammogram).

•Use of screening versus signs and symptoms codes – The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening in these cases, and a sign or symptom code is used to explain the reason for the visit.

•First listed diagnosis versus additional code

–A screening code may be the first-listed diagnosis if the reason for the visit is specifically the screening exam

–A screening code may be used as an additional code if the screening is done during an office visit for other health problems

•A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination

•Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis

•The Z-code indicates a screening exam is planned. A procedure code is required to confirm that the screening was performed

Screening Z codes/categories include:

•Z11 Encounter for screening for infectious and parasitic diseases

•Z12 Encounter for screening for malignant neoplasms

•Z13 Encounter for screening for other diseases and disorders (except Z13.9 Encounter for screening, unspecified)

•Z36 Encounter for antenatal screening of mother

Observation

There are three observation categories for use in very limited circumstances when a person is being observed for a suspected condition that has been ruled out.

•Do not use an observation code if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases, use the diagnosis/symptom code with the corresponding external cause code

•Use observation codes primarily as a principal diagnosis. However, an observation code may be assigned as a secondary code when the patient is observed for a condition that is ruled out and unrelated to the principal diagnosis, such as when a patient receives treatment for injuries sustained in a motor vehicle accident and is also observed for suspected COVID-19 infection that is subsequently ruled out. Also, when the principal diagnosis is required to be a code from category Z38 Liveborn infants according to place of birth and type of delivery. Then, a code from category Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code.

–Additional codes may be used in addition to the observation code but only if they are unrelated to the suspected condition being observed

•Codes from subcategory Z03.7 Encounter for suspected maternal and fetal conditions ruled out, may be used as either a first-listed or additional code depending on the case. Use codes from Z03.7 only when the suspected condition is ruled out during that encounter. Do not use Z03.7 codes if the suspected condition is confirmed; use the code for the confirmed condition. In addition, these codes are not for use if an illness or any signs or symptoms related to the suspected condition or problem are present. In such cases the diagnosis/symptom code is used.

–Additional codes may be used with Z03.7 codes but only if they are unrelated to the suspected condition being evaluated.

–Do not use codes from subcategory Z03.7 for antenatal screening of mother. For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category O35, O36, O40 or O41.

Observation Z codes/categories include:

•Z03 Encounter for medical observation for suspected diseases and conditions ruled out

•Z04 Encounter for examination and observation for other reasons (except Z04.9 Encounter for examination and observation for unspecified reason)

•Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out

Aftercare

Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Reporting rules for aftercare are as follows:

•The aftercare Z-code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule include:

–Codes for encounters for antineoplastic radiation, chemotherapy and immunotherapy (Z51.0, Z51.1-) are assigned as first-listed diagnosis if the sole reason for the encounter is antineoplastic therapy even if the patient still has the neoplastic disease. The neoplasm code is reported as a secondary diagnosis.

–Aftercare for injuries are not reported with Z codes. Assign the acute injury code with the appropriate 7th character for subsequent care

•The aftercare codes are generally the first-listed diagnosis

•An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of this would be the closure of a colostomy during an encounter for treatment of another condition

•Aftercare codes should be used in conjunction with any other aftercare codes, other diagnoses codes, or other categories of Z codes to provide better detail on the specifics of the aftercare encounter/visit, unless otherwise directed by the classification

•Certain aftercare Z codes require a secondary diagnosis code to describe the resolving condition or sequelae. For other aftercare codes, the condition is included in the code description and a secondary diagnosis is not required

•Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings

•Use Status Z codes with aftercare Z codes as needed to indicate the nature of the aftercare. For example, code Z95.1 Presence of aortocoronary bypass graft, may be used with code Z48.812 Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed

•Do not use a status code when the aftercare code indicates the type of status. For example, Z43.0 Encounter for attention to tracheostomy should not be used with Z93.0 Tracheostomy status

Aftercare Z codes/categories include:

•Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury

•Z43 Encounter for attention to artificial openings

•Z44 Encounter for fitting and adjustment of external prosthetic device

•Z45 Encounter for adjustment and management of implanted device

•Z46 Encounter for fitting and adjustment of other devices

•Z47 Orthopedic aftercare

•Z48 Encounter for other postprocedural aftercare

•Z49 Encounter for care involving renal dialysis

•Z51 Encounter for other aftercare and medical care

Follow-up

The follow-up Z codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists.

•Do not confuse follow-up codes with aftercare codes or with subsequent care for injuries (7th character for subsequent encounter that explains ongoing care of a healing condition or its sequelae)

•Follow-up Z codes (sequenced first) may be used with history Z codes (reported additionally) to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code

•A follow-up code may be used to explain multiple visits

•Should the condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition is reported not the follow-up Z-code

Follow-up Z code/categories include:

•Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

•Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

•Z39 Encounter for maternal postpartum care and examination

Donor

Codes in category Z52 Donors of organs and tissues, are used for living individuals who are donating blood or other body tissue. These codes are only for individuals donating for others, not for self-donations. The only exception to this rule is blood donation. There are codes for autologous blood donation in subcategory Z52.01. Codes in category Z52 are not used to identify cadaveric donations.

Counseling

Counseling Z codes are used when a patient or family member receives assistance in the aftermath of an illness or injury or when support is required in coping with family or social problems. They are not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.

Counseling Z codes/categories include:

•Z30.0- Encounter for general counseling and advice on contraception

•Z31.5 Encounter for procreative genetic counseling

•Z31.6- Encounter for general counseling and advice on procreation

•Z32.2 Encounter for childbirth instruction

•Z32.3 Encounter for childcare instruction

•Z69 Encounter for mental health services for victim and perpetrator of abuse

•Z70 Counseling related to sexual attitude, behavior and orientation

•Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified

•Z76.81 Expectant mother prebirth pediatrician visit

Encounters for Obstetrical and Reproductive Services

Z codes in pregnancy are for use in those circumstances when none of the problems or complications included in the codes for the Obstetrics chapter exist (routine prenatal visit or postpartum care). Rules for use of these codes are:

•Codes in category Z34 Encounter for supervision of normal pregnancy are always the first-listed diagnosis and are not to be used with any other code from the OB chapter

•Codes in category Z3A Weeks of gestation may be assigned to provide additional information about the pregnancy. Category Z3A codes should not be assigned for pregnancies with abortive outcomes (O00-O08), elective termination of pregnancy (Z33.2), or postpartum conditions. The date of the admission should be used to determine weeks of gestation for inpatient admissions that encompass more than one gestational week

•Codes in category Z37 Outcome of delivery should be included on all maternal delivery records. Outcome of delivery codes are always secondary codes and are never used on the newborn record

•Z codes for family planning or procreative management and counseling should be included on an obstetric record either during the pregnancy or the postpartum stage, if applicable

See Section I.C.15 Pregnancy, Childbirth and the Puerperium for further instructions on the use of these Z codes.

Z codes/categories for obstetrical and reproductive services include:

•Z30 Encounter for contraceptive management

•Z31 Encounter for procreative management

•Z32.2 Encounter for childbirth instruction

•Z32.3 Encounter for childcare instruction

•Z33 Pregnant state

•Z34 Encounter for supervision of normal pregnancy

•Z36 Encounter for antenatal screening of mother

•Z3A Weeks of gestation

•Z37 Outcome of delivery

•Z39 Encounter for maternal postpartum care and examination

•Z76.81 Expectant mother prebirth pediatrician visit

Newborns and Infants

See Section 1.C.16 Newborn (Perinatal) Guidelines for instructions on the use of these Z codes.

Newborns and infants Z codes/categories include:

•Z76.1 Encounter for health supervision and care of foundling

•Z00.1- Encounter for routine child health examination

•Z38 Liveborn infants according to place of birth and type of delivery

Routine and Administrative Examinations

Z codes allow for the description of encounters for routine examination, such as a general check-up, or examinations for administrative purposes, such as a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.

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. For example, if no abnormal findings were found during the examination, but the encounter is being coded before the test results are back, it is acceptable to assign the code for “without abnormal findings”. When assigning a code for “with abnormal findings,” additional codes should be assigned to identify the specific abnormal findings.

Preoperative examination and pre-procedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given.

Z codes/categories for routine and administrative examinations include:

•Z00 Encounter for general examination without complaint, suspected or reported diagnosis

•Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

•Z02 Encounter for administrative examination (except Z02.9 Encounter for administrative examinations, unspecified)

•Z32.0- Encounter for pregnancy test

Miscellaneous Z codes

The miscellaneous Z codes capture a number of other health care encounters that do not fall into one of the other categories. Certain of these codes identify the reason for the encounter; others are for use as additional codes that provide useful information on circumstances that may affect a patient’s care and treatment. Prophylactic organ removal is classified as a miscellaneous Z-code, and there are specific guidelines for prophylactic organ removal as follows:

•For encounters specifically for prophylactic removal of an organ, such as the breasts, the first-listed diagnosis should be a code from category Z40 Encounter for prophylactic surgery followed by the appropriate codes to identify the associated risk factor, such as family history or genetic susceptibility

•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, a code for the malignancy should also be assigned in addition to a code from subcategory Z40.0 Encounter for prophylactic surgery for risk factors related to malignant neoplasms. A code from subcategory Z40.0 should not be assigned if the patient is having organ removal for treatment of malignancy such as the removal of the testes for treatment of prostate cancer.

Miscellaneous Z codes/categories are as follows:

•Z28 Immunization not carried out (except Z28.3 Underimmunization status)

•Z29 Encounter for other prophylactic measures

•Z40 Encounter for prophylactic surgery

•Z41 Encounter for procedures for purposes other than remedying health state (except Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified)

•Z53 Persons encountering health services for specific procedures and treatment, not carried out

•Z55 Problems related to education and literacy

•Z56 Problems related to employment and unemployment

•Z57 Occupational exposure to risk factors

•Z58 Problems related to physical environment

•Z59 Problems related to housing and economic circumstances

•Z60 Problems related to social environment

•Z62 Problems related to upbringing

•Z63 Other problems related to primary support group, including family circumstances

•Z64 Problems related to certain psychosocial circumstances

•Z65 Problems related to other psychosocial circumstances

•Z72 Problems related to lifestyle

•Z73 Problems related to life management difficulty

•Z74 Problems related to care provider dependency (except Z74.01 Bed confinement status)

•Z75 Problems related to medical facilities and other health care

•Z76.0 Encounter for issue of repeat prescription

•Z76.3 Healthy person accompanying sick person

•Z76.4 Other boarder to healthcare facility

•Z76.5 Malingerer [conscious simulation]

•Z91.1- Patient’s noncompliance with medical treatment and regimen

•Z91.83 Wandering in diseases classified elsewhere

•Z91.84- Oral health risk factors

•Z91.89 Other specified personal risk factors, not elsewhere classified

Nonspecific Z codes

Certain Z codes are so non-specific or potentially redundant with other codes in the classification that there can be little justification for their use in the inpatient setting. Their use in the outpatient setting should be limited to those instances when there is no further documentation to permit more precise coding. Otherwise, any sign or symptom or any other reason for the visit that is captured in another code should be used.

Nonspecific Z codes/categories include:

•Z02.9 Encounter for administrative examinations, unspecified

•Z04.9 Encounter for examination and observation for unspecified reason

•Z13.9 Encounter for screening, unspecified

•Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified

•Z52.9 Donor of unspecified organ or tissue

•Z86.59 Personal history of other mental and behavioral disorders

•Z88.9 Allergy status to unspecified drugs, medicaments and biological substances

•Z92.0 Personal history of contraception

Z codes For Use Only as Principal/First-Listed Diagnoses

The following Z codes/categories may only be reported as the principal or first listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined:

•Z00 Encounter for general examination without complaint, suspected or reported diagnosis (except Z00.6)

•Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

•Z02 Encounter for administrative examination

•Z03 Encounter for medical observation for suspected diseases and conditions ruled out

•Z04 Encounter for examination and observation for other reasons

•Z33.2 Encounter for elective termination of pregnancy

•Z31.81 Encounter for male factor infertility in female patient

•Z31.83 Encounter for assisted reproductive fertility procedure cycle

•Z31.84 Encounter for fertility preservation procedure

•Z34 Encounter for supervision of normal pregnancy

•Z39 Encounter for maternal postpartum care and examination

•Z38 Liveborn infants according to place of birth and type of delivery

•Z40 Encounter for prophylactic surgery

•Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury

•Z51.0 Encounter for antineoplastic radiation therapy

•Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy

•Z52 Donors of organs and tissues (except Z52.9 Donor of unspecified organ or tissue)

•Z76.1 Encounter for health supervision and care of foundling

•Z76.2 Encounter for health supervision and care of other healthy infant and child

•Z99.12 Encounter for respirator [ventilator] dependence during power failure

General Documentation Requirements

The general documentation requirements for Z codes relate primarily to the need for more specific documentation related to the reason for the encounter or visit. Aftercare for conditions classified in Chapter 19 is captured with the code for the specific condition and a 7th character identifying the episode of care as a subsequent encounter. For most injuries and other conditions, the 7th character for a subsequent encounter is ‘D’, but for fractures, additional 7th characters for subsequent encounters apply.

The applicable 7th character extensions for subsequent encounters for most fractures are as follows:

DSubsequent encounter for fracture with routine healing

GSubsequent encounter for fracture with delayed healing

KSubsequent encounter for fracture with nonunion

PSubsequent encounter for fracture with malunion

The applicable 7th character extensions for fractures of the shafts of the long bones are as follows:

DSubsequent encounter for closed fracture with routine healing

ESubsequent encounter for open fracture type I or II with routine healing

FSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

GSubsequent encounter for closed fracture with delayed healing

HSubsequent encounter for open fracture type I or II with delayed healing

JSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

KSubsequent encounter for closed fracture with nonunion

MSubsequent encounter for open fracture type I or II with nonunion

NSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

PSubsequent encounter for closed fracture with malunion

QSubsequent encounter for open fracture type I or II with malunion

RSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

See Chapter 19 of the book for additional information and new coding conventions related to episode of care.

Code-Specific Documentation Requirements

In this section, code, code categories, subcategories and subclassifications for some of the more frequently reported factors influencing health status and contact with health services are reviewed. The corresponding ICD-10-CM codes are listed and the new documentation requirements identified. The focus is on conditions with specific clinical documentation requirements. Although not all ICD-10-CM codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of documentation needed for factors influencing health. The section is organized numerically by code category, subcategory, or subclassification depending on whether the documentation affects only a single code or an entire subcategory or category.

Aftercare Following Explantation of Joint Prosthesis

Two examples are listed in ICD-10-CM regarding when this code should be reported. Aftercare following explantation of joint prosthesis may be reported for a staged procedure or an encounter for evaluation of planned insertion of a new joint prosthesis following prior explantation of joint prosthesis. In ICD-10-CM, aftercare for explantation of a joint prosthesis is specific to site.

Coding and Documentation Requirements

Identify site of explantation of joint prosthesis:

•Hip

•Knee

•Shoulder

ICD-10-CM Code/Documentation
Z47.31	Aftercare following explantation of shoulder joint prosthesis
Z47.32	Aftercare following explantation of hip joint prosthesis
Z47.33	Aftercare following explantation of knee joint prosthesis

Documentation and Coding Example

Patient is a sixty-four-year-old Caucasian male now 8 weeks post explantation of left knee prosthesis who is here today to have his left knee checked and to determine if a new prosthesis can be implanted. This retired chemical engineer had a total knee arthroplasty 4 months ago and developed a staphylococcus coagulase negative wound infection postoperatively. After local surgical debridement and IV antibiotics failed to clear the infection, the prosthesis was removed and a vancomycin loaded polymethylmethacrylate cement spacer inserted into the suprapatellar pouch with extension to the gutters. Patient has had PT support 2-3 x week and serum CRP has been monitored weekly. CRP is WNL for the 2nd week in a row. The left knee has no redness or swelling, surgical incisions are clean and dry. Infection appears to have cleared up. Patient is anxious to have a new implant because he has a trip planned in 3 months. Arrangements will be made by the surgery scheduler after he has been cleared by his PMD. He is given orders for preoperative lab work, EKG, chest x-ray.

Diagnosis Code(s)

Z47.33

Aftercare following explantation of knee joint prosthesis

Coding Note(s)

In ICD-10-CM, the aftercare code is specific for aftercare following explantation of a knee joint prosthesis.

Aftercare for Healing Traumatic Fracture of Lower Leg

Aftercare of injuries in ICD-10-CM is captured with the 7th character D for routine care for most injuries. For fractures additional 7th characters for subsequent encounter apply depending on whether the fracture is open or closed and whether the healing is routine, delayed, with nonunion or with malunion.

The example below is for aftercare of a fracture of the tibial shaft.

Coding and Documentation Requirements

Identify fracture site as tibial shaft

Identify type of fracture:

•Comminuted

•Segmental

•Spiral

•Transverse

•Oblique

•Other specified fracture

•Unspecified

Identify laterality:

•Right

•Left

•Unspecified

Identify as open/closed:

•Closed

•Open

–Type I or Type II

–Type IIIA, IIIB, IIIC

Identify subsequent episode of care:

•Routine healing

•Delayed healing

•Malunion

•Nonunion

Aftercare Closed Transverse Fracture of Shaft of Tibia with Routine Healing

ICD-10-CM Code/Documentation
S82.221D	Displaced transverse fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing
S82.222D	Displaced transverse fracture of shaft of left tibia, subsequent encounter for closed fracture with routine healing
S82.223D	Displaced transverse fracture of shaft of unspecified tibia, subsequent encounter for closed fracture with routine healing
S82.224D	Nondisplaced transverse fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing
S82.225D	Nondisplaced transverse fracture of shaft of left tibia, subsequent encounter for closed fracture with routine healing
S82.226D	Nondisplaced transverse fracture of shaft of unspecified tibia, subsequent encounter for closed fracture with routine healing

Documentation and Coding Example

Thirty-seven-year-old Caucasian male reports to Orthopedic Clinic for cast change, possible application of functional brace. Patient sustained a closed, nondisplaced transverse fracture of the right tibial shaft in a snowmobile accident 4 weeks ago. The fracture was initially treated in the ER with application of a long posterior splint and subsequently casted in plaster 4 days later from mid-thigh to metatarsal heads, knee extended and ankle in 90-degree flexion. Radiographs in plaster 2 weeks ago showed good approximation of the fracture and some callus formation, repeat films today show the same with callus size increasing. Cast is removed and patient is fitted with a functional brace. He will continue to use crutches until evaluated by physical therapy. First available PT appointment is in 1 week. RTC for x-ray and recheck of brace in 2 weeks, sooner if problems arise.

Diagnosis Code(s)

S82.224D

Nondisplaced transverse fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing

Coding Note(s)

In ICD-10-CM, a single code identifies the visit as being for routine aftercare (subsequent encounter) and identifies the condition for which the aftercare is provided as a closed, nondisplaced, transverse tibial shaft fracture.

Infection with Drug-Resistant Microorganisms

There are a growing number of pathogenic microorganisms that are resistant to some or all of the drugs previously used to treat the resulting infections. In ICD-10-CM, combination codes are used for reporting MRSA infections. The codes are from infectious and parasitic diseases (sepsis) and respiratory body system (pneumonia) chapters. For a current infection due to MRSA that is not covered by a combination code, such as a wound infection, stitch abscess or urinary tract infection, the code for the condition is reported first followed by the code B95.62, Methicillin resistant S. aureus (MRSA) infection as the cause of diseases classified elsewhere to identify the drug resistant nature of the infection. Infections with other drug-resistant microorganisms are captured in Category Z16.

Coding and Documentation Requirements

Identify the drug (drug class) resistance:

•Beta lactam antibiotics

–Extended spectrum beta lactamase (ESBL)

–Penicillins, which includes:

»Amoxicillin

»Ampicillin

–Other specified beta lactam antibiotics, which includes

»Cephalosporins

•Other antibiotics

–Single antibiotics

»Quinolones/fluoroquinolones

»Vancomycin

»Vancomycin related antibiotics

»Other specified single antibiotics, which includes:

◦Aminoglycosides

◦Macrolides

◦Sulfonamides

◦Tetracyclines

–Multiple antibiotics

–Unspecified antibiotic

•Other antimicrobial drugs

–Antifungal

–Antimycobacterial (includes tuberculostatics)

»Single antimycobacterial drug

»Multiple antimycobacterial drugs

–Antiparasitic, which includes:

»Quinine and related compounds

–Antiviral drugs

–Multiple antimicrobial drugs

–Other specified antimicrobial drugs

–Unspecified antimicrobial drugs

Note: For MRSA infections, see the appropriate body system chapter.

ICD-10-CM Code/Documentation
Z16.10	Resistance to unspecified beta lactam antibiotics
Z16.11	Resistance to penicillins
Z16.12	Extended spectrum beta lactamase (ESBL) resistance
Z16.19	Resistance to other specified beta lactam antibiotics
Z16.20	Resistance to unspecified antibiotic
Z16.21	Resistance to vancomycin
Z16.22	Resistance to vancomycin related antibiotics
Z16.23	Resistance to quinolones and fluoroquinolones
Z16.24	Resistance to multiple antibiotics
Z16.29	Resistance to other single specified antibiotic
Z16.30	Resistance to unspecified antimicrobial drugs
Z16.31	Resistance to antiparasitic drug(s)
Z16.32	Resistance to antifungal drug(s)
Z16.33	Resistance to antiviral drugs
Z16.341	Resistance to single antimycobacterial drug
Z16.342	Resistance to multiple antimycobacterial drugs
Z16.35	Resistance to multiple antimicrobial drugs
Z16.39	Resistance to other specified antimicrobial drug

Documentation and Coding Example

Seventy-two-year-old Caucasian male is admitted to Rehabilitation Unit from Surgical Step Down Unit. Patient underwent emergency repair of a ruptured aortic aneurysm 22 days ago. His post-operative course has been complicated by ARDS, renal failure and sepsis. He has a G-Tube for supplemental nutrition. Foley catheter was discontinued one week ago. There is a Hep-Lock in his left forearm for IV antibiotics, site has no redness or swelling. T 97.6, P 100, R 16, BP 128/90, Wt. 138 lbs. On examination, this is a thin, frail, tired appearing elderly gentleman. He is oriented to person and place but becomes a little confused when asked for the date. He does know the month and year and with prompting comes up with an appropriate day of the week. PERRL, oral mucosa is pale and dry. Skin is warm and dry. Pulses are weak in both upper and lower extremities with decreased muscle tone and muscle wasting but no edema appreciated. Heart rate regular without bruit, rub or murmur. Breath sounds have fine scattered rales throughout with decreased sounds in the bases. Respirations are somewhat shallow and labored. O2 sat on 2 L O2 via NC is 96%. There is a surgical scar down the midline of the abdomen extending from the xyphoid to just above the pubic bone. Distal and proximal ends are healing but a 2 cm open area remains just below the umbilicus. A 4 x 4 gauze dressing has a small amount of yellow-green drainage. G-tube site is clean and the tube is patent. Abdomen firm with active bowel sounds. Male genitalia is normal. Transfer notes indicate the abdominal wound is positive for vancomycin resistant enterococci. He is currently receiving IV Synercid and appears to be responding well to this antibiotic. Patient will be in wound and skin isolation but can begin PT and OT. Speech will evaluate him for swallowing and order an appropriate diet.

Diagnosis Code(s)

T81.41XA	Infection following procedure, superficial incisional surgical site, subsequent encounter
B95.2	Enterococcus as the cause of diseases classified elsewhere
Z16.21	Resistance to vancomycin

Coding Note(s)

The patient is being transferred to a rehabilitation unit where he will continue to receive antibiotic therapy for the postoperative infection. This is classified as aftercare. Multiple diagnosis codes are required to capture all aspects of his condition.

The aftercare is the first-listed diagnosis. Aftercare related to a post-operative wound infection is reported with a code from subcategory T81.4- in Chapter 19 Injuries, Poisonings, and Other Consequences of External Causes, so 7th character D for subsequent encounter is reported for this phase of his care. There is no mention of the incisional wound infection reaching a depth beyond the skin and subcutaneous tissues, so the postoperative wound infection is reported at the superficial incisional surgical site level. The microorganism, enterococcus, responsible for the infection is reported secondarily as is the drug resistance to vancomycin.

Pregnancy, Normal

Codes for normal pregnancy are for use when the patient is seen for normal, uncomplicated prenatal care and are always the first-listed diagnosis. Codes in category Z34 Encounter for supervision of normal pregnancy are for use in those circumstances when none of the problems or complications included in the codes for the Obstetrics chapter exist (a routine prenatal visit or postpartum care). Codes in category Z34 Encounter for supervision of normal pregnancy are always the first-listed diagnosis and are not to be used with any other code from the OB chapter.

Coding and Documentation Requirements

Identify encounter for supervision of pregnancy:

•Normal first pregnancy

•Other normal pregnancy

•Unspecified normal pregnancy

Identify trimester:

•First trimester

•Second trimester

•Third trimester

•Unspecified trimester

ICD-10-CM Code/Documentation
Z34.00	Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01	Encounter for supervision of normal first pregnancy, first trimester
Z34.02	Encounter for supervision of normal first pregnancy, second trimester
Z34.03	Encounter for supervision of normal first pregnancy, third trimester
Z34.80	Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81	Encounter for supervision of other normal pregnancy, first trimester
Z34.82	Encounter for supervision of other normal pregnancy, second trimester
Z34.83	Encounter for supervision of other normal pregnancy, third trimester
Z34.90	Encounter for supervision of normal unspecified pregnancy, unspecified trimester
Z34.91	Encounter for supervision of normal unspecified pregnancy, first trimester
Z34.92	Encounter for supervision of normal unspecified pregnancy, second trimester
Z34.93	Encounter for supervision of normal unspecified pregnancy, third trimester

Documentation and Coding Example

Twenty-nine-year-old Black female is seen in OB Clinic for routine monitoring of pregnancy. Patient is a primigravida now at 20 weeks gestation with a singleton male fetus per ultrasound. She states she is feeling well. Nausea and tiredness have gone away. She is starting to wear maternity clothes and is enjoying the attention as she shares the news of her pregnancy with friends and family. P 84, R 14, BP 122/72, Wt. 138 lbs. Urine sample is dipstick negative for protein and glucose. On examination, the FHB is heard via Doppler, strong and regular at 136 bpm. Fundal height is consistent with dates. Patient states she feels fetal movement daily, denies abdominal pain, discomfort with intercourse, bleeding or vaginal discharge. Her appetite is improving, she is eating a variety of foods and has no unusual cravings. Questions are answered. She is counseled regarding what to expect in the next few weeks and what symptoms should be promptly reported. RTC in 3 weeks.

Diagnosis Code(s)

Z34.02

Encounter for supervision of normal first pregnancy, second trimester

Coding Note(s)

The patient is being seen for a normal uncomplicated first pregnancy and she is in her second trimester so code Z34.02 is assigned. The timeframes for the trimesters are indicated at the beginning of Chapter 15.

Routine General Medical Examination Newborn/Infant/Child/Adult

Routine encounters for medical examinations include well newborn examination, infant/child check-ups, and annual medical examinations of adults. A newborn is defined as being under 29 days old. An infant/child is defined as being over 28 days old. Since these are some of the most frequently reported codes from Chapter 21 in ICD-10-CM, they have been arranged in the first code block, Z00-Z13 Persons encountering health services for examinations. Codes for routine medical examinations are contained in the first category, Z00 Encounters for general examination without complaint, suspected or reported diagnosis. One of the key things to note is that codes for infants, children, and adults are specific as to whether or not there are any abnormal findings on the examination. For newborns, there is a coding instruction indicating that additional codes should be assigned for any abnormal findings.

Coding and Documentation Requirements

Identify routine health check:

•Adult

•Child

•Newborn

–Under 8 days old

–8-28 days old

Identify presence/absence of abnormal findings:

•With abnormal findings

•Without abnormal findings

Use an additional code for any abnormal findings.

ICD-10-CM Code/Documentation
Z00.110	Health examination for newborn under 8 days old
Z00.111	Health examination for newborn 8 to 28 days old
Z00.121	Encounter for routine child health examination with abnormal findings
Z00.129	Encounter for routine child health examination without abnormal findings
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings

Documentation and Coding Example

Fifty-one-year-old Hispanic male presents to PCP for routine physical. He is feeling well and has no health concerns since his last visit 13 months ago. Patient is a high school history teacher, his wife works in an elementary school office and their daughter is now 10 years old. He is finished with classes for the summer and looking forward to a week of relaxation before he tackles some home repair projects. He admits to a pretty sedentary lifestyle and he knows he has gained weight this past year.

T 97.4, P 90, R 14, BP 144/72, Wt. 213, Ht. 71 inches. On examination, this is a well-developed, well-nourished adult male. PERRL, neck supple without lymphadenopathy. Patent nares, there is a slight deviation of the septum toward the right but it does not obstruct air flow. Mucous membranes moist and pink, there is marked atrophy of tonsil and adenoid tissue. The posterior pharynx has a cobblestone appearance suggestive of allergies but patient denies symptoms. Heart rate regular, carotid arteries are without bruit. Peripheral pulses present and WNL. Breath sounds clear and equal bilaterally. Abdomen mildly obese with active bowel sounds. Liver palpated at 2 cm below the RCM, spleen is not palpable. No evidence of hernia. Testicles smooth, penis uncircumcised, foreskin retracts easily, hygiene excellent. Rectal exam shows good sphincter tone and a small, smooth prostate. Labs were drawn prior to this appointment and results are reviewed with patient. His BGL is normal. Cholesterol and triglycerides are in the high normal range. Of concern however is elevated protein in his urine.

Diagnosis: Routine health exam, with routine labs showing elevated protein in urine.

Plan: Patient is referred to Nephrology for complete evaluation of his renal function.

Diagnosis Code(s)

Z00.01	Encounter for general adult medical examination with abnormal findings
R80.9	Proteinuria, unspecified

Coding Note(s)

The patient has an elevated level of protein in his urine which is an abnormal finding that could be indicative of kidney disease. The code for encounter for general adult health examination with abnormal findings is sequenced first since the routine examination was the reason for the visit. The abnormal laboratory finding is reported as an additional diagnosis.

Summary

Codes that report factors influencing health and contact with health services require specific documentation of the reason for the encounter. This may involve identification of additional factors that may affect future care of the patient such as an annual adult preventive medicine examination in which there are abnormal findings. It may involve specific documentation related to the type of aftercare provided, such as aftercare related to prosthetic joint explantation which requires identification of the joint, or it may require specific documentation related to other factors influencing health such as patient medical noncompliance (Z91.1-) which now allows identification of various reasons including financial hardship or age-related debility. Coders also need to be aware of the classification of aftercare codes for injuries, poisoning, and certain other consequences of external causes and coding conventions related to reporting these aftercare services. A careful review of current documentation related to encounters/visits for these factors influencing health status is required in order to ensure that any documentation deficiencies are identified and corrected.

Resources

Documentation checklists are included in Appendix A for the following factors influencing health and contact with health care services:

•Examination, administrative

•Examination, general medical/specialty

•Examination, gynecological/contraception

•Examination, obstetrics/reproductive

Chapter 20 Quiz

1.Which code for factors influencing health and contact with health services would NOT be reported as the first listed diagnosis?

a.Z00.01 Encounter for general adult medical examination with abnormal findings

b.Z16.11 Resistance to penicillins

c.Z38.00 Single liveborn infant, delivered vaginally

d.Z51.0 Encounter for antineoplastic radiation therapy

2.Status Z codes are defined as:

a.Codes that indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition

b.Codes that explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring

c.Codes that cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease

d.Codes that explain continuing surveillance following completed treatment of a disease, condition, or injury

3.Identify which circumstance requires the use of a screening code.

a.Testing is performed to rule out or confirm a suspected diagnosis because the patient has some sign or symptom

b.A screening, such as a pap smear, is performed during a routine examination

c.Testing is performed in an apparently well (symptomless) individual for early detection of a disease

d.An office visit for a specific health problem in which a test is performed to more specifically identify the health problem

4.What information is required to report the most specific code for supervision of a normal first pregnancy?

a.Number of fetuses

b.Results of routine laboratory tests

c.The number of prenatal visits

d.Weeks of gestation or trimester

5.Identify which statement is true related to Z codes.

a.Z codes may be used only in the outpatient setting

b.Certain Z codes may only be used as a first listed or principal diagnosis.

c.Z codes describe both reason for the encounter and the procedure performed so a procedure code is not reported additionally

d.All of the above statements are true

6.The physician has documented that the patient is being seen for an annual preventive exam. On this visit, the physician notes that the patient has an elevated blood pressure of 150/96 which has not been present on previous visits. He wants to determine if this is an isolated finding or if the patient has hypertension and requests that the patient return for blood pressure checks. Identify the correct assignment and sequencing of the diagnosis codes.

a.Z00.00, I10

b.R03.0, Z00.01

c.Z00.01, R03.0

d.I10, Z00.01

7.A code from category Z79 Long-term (current) drug therapy would be reported under which circumstance?

a.For a patient receiving a medication for an extended period as a prophylactic measure

b.For a patient being administered a medication for a brief period of time to treat an acute illness or injury

c.For a patient who is addicted to a drug

d.For a patient receiving medications for detoxification or maintenance programs to prevent withdrawal symptoms due to drug dependence

8.Identify the false statement related to code Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours.

a.Code Z92.82 is reported on the receiving hospitals medical record when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility

b.Do not report Z92.82 if the patient is still receiving the tPA at the time they are received into the current facility

c.The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first

d.Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record

9.In what category of Z codes is code Z77.22 Exposure to tobacco smoke (second hand smoke) classified?

a.Status

b.History (of)

c.Miscellaneous

d.Contact/Exposure

10.Preoperative examination and pre-procedural laboratory examination Z codes are for use under what circumstances?

a.When the primary care physician is working up a patient for signs and symptoms to determine if a procedure is required

b.When a specialist is evaluating a patient for a condition that may require surgery

c.In those situations when a patient is being cleared for a procedure or surgery and no treatment is given

d.All of the above

Chapter 20 Answers and Rationales

1.Which code for factors influencing health and contact with health services would NOT be reported as the first listed diagnosis?

b.Z16.11 Resistance to penicillins

Rationale: Codes for drug-resistance to antibiotics are listed as secondary diagnoses. The condition being treated, in this case an infection such as bacterial pneumonia or wound infection, is reported as the first-listed diagnosis.

2.Status Z codes are defined as:

a.Codes that indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition

Rationale: Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease. The other definitions listed are for history (personal) Z codes, aftercare Z codes, and follow-up Z codes respectively.

3.Identify which circumstance requires the use of a screening code.

c.Testing is performed in an apparently well (symptomless) individual for early detection of a disease

Rationale: Screening is performed for the early detection of disease so that prompt treatment can be provided for those who test positive for the disease. Inherent screenings such as a pap smear performed during an annual examination does not require a screening code. The other two answers describe diagnostic exams and the code for the sign, symptom, or medical condition would be reported not a screening code.

4.What information is required to report the most specific code for supervision of a normal first pregnancy?

d.Weeks of gestation or trimester

Rationale: Supervision of normal pregnancy is specific to trimester so either the weeks of gestation or the trimester must be documented.

5.Identify which statement is true related to Z codes.

b.Certain Z codes may only be used as a first listed or principal diagnosis.

Rationale: While most Z codes may be used as first-listed or additional diagnosis, certain Z codes may only be used as a first-listed or principal diagnosis. Z codes may be used in any healthcare setting not just outpatient settings. Z codes describe the reason for the encounter, but they are not used for reporting the procedure which must be reported with a CPT, HCPCS or ICD-10-PCS procedure code.

c.Z00.01, R03.0

Rationale: The code for encounter for general adult medical examination with abnormal findings is reported as the first listed diagnosis. Since the physician has not diagnosed the patient as having hypertension, a symptom code for the elevated blood pressure is also reported to identify the abnormal finding.

7.A code from category Z79 Long-term (current) drug therapy would be reported under which circumstance?

a.For a patient receiving a medication for an extended period as a prophylactic measure

Rationale: Codes from this category indicate a patient’s continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use. Assign a code from category 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 treatment (such as cancer). A code from category Z79 is not assigned for medications being administered briefly to treat an acute condition, for patients who have addictions to drugs, or for patients with drug dependency receiving drugs for detox or on maintenance programs.

8.Identify the false statement related to code Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours.

b.Do not report Z92.82 if the patient is still receiving the tPA at the time they are received into the current facility

Rationale: Code Z92.82 is reported even if the patient is still receiving the tPA at the time they are received by the receiving facility.

9.In what category of Z codes is code Z77.22 Exposure to tobacco smoke (second hand smoke) classified?

d.Contact/Exposure

Rationale: Category Z77 indicates contact with or suspected exposure to substances that are known to hazardous to health. Code Z77.22 Exposure to tobacco smoke (second hand smoke) is included in this category.

10.Preoperative examination and pre-procedural laboratory examination Z codes are for use under what circumstances?

c.In those situations when a patient is being cleared for a procedure or surgery and no treatment is given

Rationale: Preoperative examination and preprocedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given.