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CODING ALERT

Reasons for health services encounter get codes in Chapter 21 of ICD-10

By Judy Monestime  bio

Codes included in Chapter 21, Factors influencing health status and contact with health services (Z00-Z99), represent reasons for encounter. Z codes are provided for encounters when circumstances other than diseases or injury are recorded in the medical record as the diagnosis.

The chapter includes the following sections:

  • 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-Z28, 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 with potential health hazards 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

The note at the beginning of this chapter has been modified from what it states in ICD-9 CM. All codes in Chapter 21 are affected by these revised guidelines:

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:

  • b) 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 prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
  • a) When some circumstance or problem is present which influences the person’s health status but is not in itself a current illness or injury

Persons encountering health services for examination (Z00-Z13)

The use of the codes from this section is for patients who may not be acutely ill but require or request an examination, for example, routine physician examinations, and examination for pre-employment, entrance into the military, sports participation, and insurance reasons.

Category Z00, Encounter for general examination without complaint, suspected or reported diagnosis
These codes in category Z00 describe a reasonably healthy adult or child who seeks health care services for routine examination, such as general physical examination. In most cases, the codes are only used as first-listed diagnosis. If a condition is identified during the examination, it should be reported as an additional diagnosis code. Preexisting or chronic conditions, as well as history codes, may also be used as additional diagnoses as long as the examination was for an administrative purpose and not focused on treatment of the medical condition.

Let’s practice! How do you code the following encounter?

A 45-year-old woman has an appointment at her primary care physician’s office for her annual physician examination. The patient has mild eczema that is treated with OTC lotions.

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

L30.9 Dermatitis, unspecified

Rationale: The encounter was for an adult periodic examination. During the examination, a condition is identified. The instructional note next to codes Z00.1 states, “Use additional code to identify abnormal findings.”

Judy Monestime, MBA, CDIP, CPC, is an AHIMA-approved ICD-10-CM/PCS trainer.

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