MEDESUN HEALTHCARE SOLUTIONS
Z-Codes ICD-10-CM
Not all patient encounters are for a problem or condition. Chapter 21 of ICD-10-CM includes codes reported to identify the reason why the patient is receiving services when a disease or disorder is not the reason the services are rendered.
Z-Codes are reported when the patient is not sick and Codes in 21 chapter are referred to as Z codes presents for specific care Z-Codes can be used in any healthcare setting. They can be sequenced as primary or secondary codes.
”
Encounter for Vaccination
Contact/ Exposure Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who are suspected to have been exposed to a disease by close personal contact with an infected individual or are located in an area where a disease is epidemic. Examples include contact with or exposure to an intestinal infectious disease, tuberculosis, HIV, Zika virus, or COVID-19.
ExampleContact with and (suspected) exposure to COVID-19-Z20.822-New Code
History (of) There are two types of history Z codes, personal and family. 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. Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
Examples-History 1. Family history of polyps of the colon Z83.71
2. A patient presents complaining of a lump in her left breast. She has a family history of breast cancer. The provider orders a mammogram. The correct codes to report and sequence are: N63.20 Unspecified lump in the left breast, unspecified quadrant Z80.3 Family history of malignant neoplasm of breast
3. ED Summary Note Kyle presented to the ED with abdominal distention and tenderness, a fever of 102, and a complaint of nausea. Kyle has a history of perforated peptic ulcer. Physical exam was performed, along with arterial blood gases (which showed lowered potassium and carbon dioxide), urinalysis, and lab tests, all of which confirm the diagnosis of generalized acute peritonitis. What ICD-10-CM code(s) are reported? A.K65.0, Z87.19 B.K65.0, Z87.11 C.Z87.11, K65.0 D. Z87.19, K65.0 Answer- B
Screening Examinations Z11 through Z13 The purpose of preventive medicine is to identify potential health problems before they become severe. Screening is performed on apparently well individuals who present no signs or symptoms relative to the disease Colonoscopies are performed as a screening test for colon cancer. The proper diagnosis code is Z12.11 Encounter for screening for malignant neoplasm of colon. When the purpose of the encounter is for screening, and the provider finds an abnormality, first sequence the code for the screening, followed by any abnormal findings.
For example, during a screening colonoscopy the provider finds and removes a polyp. The first listed code is the screening for colon cancer (Z12.11), followed by the code for the polyp (K63.5).
Examples-Screening 1. A patient undergoes routine mammography, which reveals no pathology. Code Z12.31, Encounter for screening mammogram for malignant neoplasm of breast, is assigned.
2. An asymptomatic patient undergoes a screening mammography. The radiologist reports the presence of microcalcifications. Assign code Z12.31, Encounter for screening mammogram for malignant neoplasm of breast, followed by code R92.0, Mammographic microcalcification found on diagnostic imaging of breast.
3. A patient with a family history of breast cancer in her mother, aunt, and older sister presents for a screening mammogram because she is considered at high risk for the disease. Assign code Z12.31, Encounter for screening mammogram for malignant neoplasm of breast, followed by code Z80.3, Family history of malignant neoplasm of breast.
Special Investigations and Examinations
When a patient receives only diagnostic services during an episode of care, a code for the condition or problem that was chiefly responsible for the encounter is assigned first. A code from category Z01
A patient is referred to the radiology department for a chest X-ray as part of a routine physical examination. Code Z00.00, Encounter for general adult medical examination, is listed as the reason for the encounter because there are no presenting symptoms and the Xray was not performed to rule out any suspected disease
A patient is examined for a cough and referred to the radiology department for a chest X-ray, which may rule out pneumonia. The radiologist’s report indicates that the X-ray is normal. The code for the cough (R05) is listed as the reason for the encounter. A code for pneumonia is not assigned; neither is a code assigned from category Z01.
Preoperative Examination
Aftercare
Code Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, may be assigned as the reason for encounter only when the patient is no longer receiving treatment.
Admission for Observation and Evaluation
Categories Z03 and Z04 can also be used for administrative and legal observation status
Review Once Again
Z08
Z09
Z03
Z04
Z CODES
•
Can be Primary or Secondary
History, Screening, Status, Aftercare,
Codes
Follow-up
•
Report codes as applicable.
Donor, Counselling, Outcome of Delivery
•
Z codes can be used in any
Preoperative Examination etc.
healthcare setting.
Index entries for Z codes are included in the main
Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65)
Alphabetic Index. These are the key main terms: •Admission •Examination •History •Observation •Aftercare •Problem •Status
Examples 1. The patient complains to her family practitioner of blood in her sputum. An x-ray shows a coin lesion in the right lung. The patient is seven years post-mastectomy for breast cancer. Smoking occasionally. The history of breast cancer is pertinent to the patient’s chief complaint. Although the patient has been symptom-free for seven years, her history of breast cancer will contribute to the diagnostic path the physician chooses. Report: R04.2 Hemoptysis R91.1 Other coin lesion lung Z85.3 Personal history of malignant neoplasm of breast Z72.0 Tobacco use 2. David went camping last month in the Rockies with several friends who now have been diagnosed with dysentery, protozoal , drinking from the mountain stream. John also drank from the stream but has no symptoms. Prescribed a 10day course of Flagyl. John did not have a chief complaint and had no symptoms. He presented for a screening test and laboratory results indicated an infection. Report: Z11.0 Encounter for screening for intestinal Infectious diseases A07.9 Protozoal Dysentery
MEDESUN QUESTIONSINFO@MEDESUN.COM
LOGIN TO LMS AND TAKE ASSESSMENTS
Learn MORE DO MORE BE MORE