Basic ICD-10-CM/PCS Coding 2013 Edition

1. Basic ICD-10-CM/PCS Coding2013 Edition Chapter 24: Factors Influencing Health Status and Contact with Health Services (Z00–Z99)

2. Learning Objectives • Review the chapter’s learning objectives and key terms • Concepts in this chapter require extra study time • Z codes may be difficult to understand at first • Many different types of Z codes • Student must pay particular attention to definitions and coding rules • At the conclusion of this chapter, what must you know about the intended meaning and use of Z codes?

3. Factors Influencing Health Status and Contact with Health Services (Z00–Z99) • Z codes are ICD-10-CM diagnosis codes that describe reasons for health services • Z codes are not procedure codes even though the code may describe the fact that a procedure has occurred

4. Categories in Chapter 21 of ICD-10-CM • Z00–Z13: Persons encountering health services for examination • Z14–Z15: Genetic carrier and genetic susceptibility to disease • Z16: Resistance to antimicrobial drugs • Z17: Estrogen receptor status • Z18: Retained foreign body fragment

5. Categories in Chapter 21 of ICD-10-CM • 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

6. Categories in Chapter 21 of ICD-10-CM • Z55–Z65: Persons with potential health hazards related to socioeconomic and psychosocial circumstances • Z66: Do not resuscitate status • Z67: Blood type

7. Categories in Chapter 21 of ICD-10-CM • 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

8. ICD-10-CM Factors Influencing Health Status and Contact with Health Services—Z Codes • Z codes are diagnosis codes that represent reasons for encounters • Z codes are provided for encounters when circumstances other than disease or injury are the reason for seeking health care services • If a procedure is performed, a corresponding procedure code must be used

9. ICD-10-CM Factors Influencing Health Status and Contact with Health Services—Z Codes • Titles of Z code categories have titles to describe the situation the code will classify • Encounter for follow-up examination after completed treatment for malignant neoplasm • Encounter for general adult medical examination • Encounter for immunization

10. Instructional Notes for ICD-10-CM Chapter 21 • Instructional notes are available for different categories to explain how codes should be assigned • “Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examination or procedure performed”

11. Instructional Notes for ICD-10-CM Chapter 21 • Instructional note under category Z85, Personal history of malignant neoplasm, is the following note: • Code first any follow-up examination after treatment of malignant neoplasm (Z08)

12. Coding Guidelines for ICD-10-CM Chapter 21 • Chapter-specific guidelines exist for Chapter 21 • Use of Z codes in any healthcare setting • Z codes indicate a reason for an encounter • Categories of Z codes • Contact/exposure • Inoculations and vaccinations • Status • History (of)

13. Coding Guidelines for ICD-10-CM Chapter 21 • Chapter-specific guidelines exist for Chapter 21 • Categories of Z codes (continued) • Screening • Observation • Aftercare • Follow-up • Donor • Counseling • Encounters for Obstetrical and Reproductive Services

14. Coding Guidelines for ICD-10-CM Chapter 21 • Chapter-specific guidelines exist for Chapter 21 • Categories of Z codes (continued) • Newborns and infants • Routine and administrative examinations • Miscellaneous Z codes • Nonspecific Z codes • Z codes that may only be principal/first listed diagnoses

15. Coding Factors Influencing Health Status and Contact with Health Services in ICD-10-CM • Z codes are used in ambulatory, inpatient, and post-acute care settings • Used for patients who may or may not be sick but the person needs healthcare services for a particular reason

16. Coding Factors Influencing Health Status and Contact with Health Services in ICD-10-CM • Z codes can describe when a patient • Receives a prophylactic vaccination or immunization • Is a organ or tissue donor • Needs counseling or other services to address a problem that is not a disease or illness • Review the outline of Z codes provided in text

17. Coding Factors Influencing Health Status and Contact with Health Services in ICD-10-CM • Z codes are assigned more frequently in hospital ambulatory care departments or primary care sites, such as physicians’ offices, than in acute care inpatient facilities • Z codes are used as either first-listed or secondary diagnosis codes, but certain Z codes may only be used as first-listed codes

18. Main Terms in ICD-10-CM • Z codes are indexed in the ICD-10-CM Alphabetic Index to Diseases with other diagnoses and reasons for health services • Look for terms that describe the reason for the encounter or admission • Why is the patient receiving services?

19. Main Terms in ICD-10-CM (continued) • When looking for a main term in ICD-10-CM for a Z code, ask yourself: • What are the terms that describe the reason for the encounter or admission? • Why is the patient receiving services? • What is going to be done for the patient today?

20. Commonly Used Main Terms in ICD-10-CM • Admission (encounter) for • Attention to • Carrier (suspected) of • Chemotherapy • Dialysis • Donor • Examination

21. Commonly Used Main Terms in ICD-10-CM (continued) • Fitting (of) • History (personal) of • Newborn • Observation • Outcome of delivery • Prophylactic

22. Commonly Used Main Terms in ICD-10-CM (continued) • Replacement by…device or prosthesis • Resistance, resistant • Status • Supervision (of) • Therapy • Transplant(ed) • Vaccination

23. Persons Encountering Health Services for Examination (Z00–Z13) • Used for patients who may not be acutely ill but require or request an examination • Routine physicals, pre-employment, entrance into military, sports participation, or insurance purposes • Observed for suspected conditions that later were proven not to exist • Followup examinations following completed treatments of malignancy or other conditions

24. Persons Encountering Health Services for Examination (Z00–Z13) • Category Z00, Encounter for general examination without complaint, suspected or reported diagnosis • Routine examinations: adult and children • First-listed diagnosis code • Distinguish between exam with and without abnormal findings • Additional diagnosis code used for condition identified during the exam • Pre-existing conditions can also be coded • Indexed under “admission (encounter), for examination” and “examination”

25. Persons Encountering Health Services for Examination (Z00–Z13) • Category Z03, Encounter for medical observation for suspected diseases and conditions ruled out • Patient suspected of having abnormal condition • Patient does not have any signs or symptoms but requires study for suspected condition • Test results and examinations prove the condition does not exist or the condition was “ruled out” • If a patient has signs or symptoms of a suspected disease, the coder should assign a code for the sign or symptoms instead of the Z03 category codes

26. Persons Encountering Health Services for Examination (Z00–Z13) • Category Z04, Encounter for examination and observation for other reasons • Encounters primarily for medical legal reasons • Person is suspected of having an abnormal condition but does not have signs or symptoms of the condition • After study it is proven the condition does not exist or is ruled out • Examples of situations coded here are work accidents, alleged rape, requested psychiatric examination by authority and following alleged physical abuse

27. Persons Encountering Health Services for Examination (Z00–Z13) • Category Z08, Encounter for follow-up examination after completed treatment for malignant neoplasm • Category Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm • Follow-up codes explain medical surveillance following completed treatment • The patient’s condition no longer exists • Follow-up codes may be used with history codes to fully describe patient • Review notes under categories Z08 and Z09 • Indexed under “Examination, follow-up”

28. Persons Encountering Health Services for Examination (Z00–Z13) • Category Z12, Encounter for screening for malignant neoplasm • Screening is defined as testing for a disease in asymptomatic patient • Screening is intended to detect an unidentified condition so that it can be treated properly • Use additional codes for family history of disease • Used for encounters for screening colonoscopy, screening mammography, screening Pap smear • Category Z13, Encounter for screening of other diseases or conditions • Screening for certain developmental disorders in childhood, screening for osteoporosis, screening for traumatic brain injury

29. Resistance to Antimicrobial Drugs (Z16) • Category Z16 should be used as an additional code to indicate the resistance and nonresponsive of a condition to an antimicrobial drug • Z16 are used when the documentation indicates that a patient’s infection has a known causative bacteria or other organism that is resistant to the medication therapy administered • Code first the infection to identify the type and site of current infection present in the patient known to be drug resistant • Sepsis (A41.9) with infection resistant to vancomycin (Z16.21) • Indexed under “resistance, resistant (to) drug, followed by drug type or name”

30. Estrogen Receptor Status (Z17) • Z17.1, Estrogen receptor positive status [ER+] • Z17.2, Estrogen receptor negative status [ER-] • Used as additional code for patient who have been diagnosed with breast cancer and have had their estrogen status determined • Both women and men, greater incidence among postmenopausal women • Patients more like to benefit from endocrine therapies

31. Retained Foreign Body Fragment (Z18) • Embedded foreign body fragment status to identify the type of embedded material • Requested by military personnel to identify persons who have had an injury and the fragment has not been removed • Embedded object has potential for infection or is a contraindication for certain imaging studies • Identifies radioactive, metal, plastic, organic or other types of foreign body fragments

32. Persons with Potential Health Hazards Related to Communicable Diseases (Z20–Z28) • Patient has come in contact with, or has been exposed to, a communicable disease • Patient does not have signs or symptoms of disease exposed to or come in contact with • Z20, Contact with and (suspected) exposure to communicable diseases are first-listed codes to explain an encounter for testing • Z21, Asymptomatic Human Immunodeficiency Virus (HIV) Infection status, is code used for the patient with positive HIV virus status but no symptoms of the infection or AIDS

33. Persons with Potential Health Hazards Related to Communicable Diseases (Z20–Z28) • Z22, Carrier of Infectious Disease • Describe colonization status or the presence on or in the body of a particular organism without it causing an illness in the patient • Patient is a carrier or suspected carrier of an infectious disease but currently does not exhibit symptoms of the disease • Carrier of specific bacterial diseases, viral hepatitis and other viral or infectious diseases

34. Persons with Potential Health Hazards Related to Communicable Diseases (Z20–Z28) • Z23, Encounter for immunization • Any encounter when the purpose of the visit is to receive prophylactic inoculation against a disease • Procedure code used to show inoculation occurred • Used as secondary codes during well-baby or well-child visits • The type of vaccine administered is not identified by diagnosis code Z23 • Main terms immunization, prophylactic, or vaccination

35. Persons with Potential Health Hazards Related to Communicable Diseases (Z20–Z28) • Z28, Immunization not carried out and under immunization status • Codes describe specific reasons why an immunization or vaccination was not given, such as • Medical contraindication • Patient’s decision not become immunized • Patient has already had illness the vaccine is intended to prevent • Parent or guardian’s refusal to have it done • Code Z28.3, Under immunization status, identifies the patient who has not received the vaccination that are appropriate for the person’s age

36. Persons Encountering Health Services in Circumstances Related to Reproduction (Z30–Z39) • Healthcare services related to contraceptive and procreative management • Status of newborn at time of birth, place where infant was born and type of delivery • How many infants born to a mother • Supervision of pregnancy during an uncomplicated, normal pregnancy

37. Persons Encountering Health Services in Circumstances Related to Reproduction (Z30–Z39) • Z30, Encounter for contraceptive management • Initial prescription of contraceptives, counseling and instruction for natural family planning, surveillance of contraceptives such as repeat prescription • Main term “contraception, contraceptive” • Code Z30.2, Encounter for sterilization, is additional diagnosis when a sterilization is performed during the same admission as a delivery. It may also be first-listed or principal diagnosis when the admission is solely for sterilization • Codes exist for insertion, removal or checking of an IUD

38. Persons Encountering Health Services in Circumstances Related to Reproduction (Z30–Z39) • Z31, Encounter for procreative management • Health care services related to producing an offspring • Genetic testing and infertility services • Genetic counseling and advice on procreation • Encounter for assisted reproductive fertility procedure cycle • Healthcare encounters for reversal of a previous tubal ligation or vasectomy, artificial inseminations, procreative investigations and testing

39. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z32, Encounter for pregnancy test and childbirth and childbirth instruction • Identify an encounter when the result of a pregnancy test is positive, negative, or unknown. • Other codes describe encounters for childbirth instruction and childcare instruction

40. Persons Encountering Health Services in Circumstances Related to Reproduction (Z30–Z39) • Z33, Pregnant State • Code Z33.1, Pregnant state, incidental, is used to identify the fact that a patient is pregnant • This code is used then the provider documents that the pregnancy is incidental or unrelated to the encounter • Code Z33.1 is used in place of an obstetric code from Chapter 15 • It is the provider’s responsibility to state that the patient’s condition being treated is not affecting the pregnancy

41. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z33, Pregnant State • Code Z33.2, Encounter for elective termination of pregnancy • Represents the healthcare encounter when a patient has requested an elective abortion or termination of pregnancy • Procedure code is used to identify the abortion procedure performed • This code is not used if the encounter was for the purpose of completing a procedure to terminate the pregnancy for an early fetal death or for treatment of a spontaneous abortion

42. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z34, Encounter for supervision of normal pregnancy • Z34.0, Encounter for supervision of normal first pregnancy • Z34.8, Encounter for supervision of other pregnancy • Generally used in outpatient settings and for routine prenatal visits • When a complication of the pregnancy is present, the code for that condition is assigned rather than a code from category Z34 • Indexed under “pregnancy, normal, supervision (of)(for)

43. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z36, Encounter for antenatal screening of mother • Testing of the female during pregnancy for a variety of conditions and abnormalities • Describes the female, not the fetus, and used to indicate the screening was planned • Abnormal finding or condition should be coded as an additional code with the Z36 screening category code • Z36 is not used if the female is tested because of some sign or symptom • A procedure code is required to confirm the screening is performed

44. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z3A, Weeks of gestation • Used on the mother’s record to indicate the weeks of gestation for the current pregnancy • The diagnosis codes for the complications of pregnancy, childbirth and the puerperium (O00–O9A) are coded first followed by the weeks of gestation codes • These codes are used at any time during the patient’s pregnancy and not just at the time of the delivery

45. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z37, Outcome of delivery • Always a secondary code that should be included on every maternal record when a delivery has occurred • Indicates whether the delivery produced a single or multiple birth and whether the infants were live births or stillbirths

46. Persons Encountering Health Services in Circumstances Related to Reproduction(Z30–Z39) • Z38, Liveborn infants according to place of birth and type of delivery • Always the first code listed on the health record of a newborn • “Once in a lifetime” code and not reported when the newborn is transferred to another institution or an infant’s subsequent admission or outpatient visit • Indicate single or multiple live birth • Main term “newborn, born in hospital or born outside of hospital” • Additional codes assigned for disease or injury present

47. Encounters for Other Specific Health Care (Z40–Z53) • Categories Z40–Z53 • intended for use to indicate a reason for care in patients who may have already been treated for some disease or injury not now present, or who are receiving aftercare or prophylactic care consolidate the treatment or to deal with residual states • Z40, Encounter for prophylactic surgery • Codes identify encounter for prophylactic organ removal, for example, in a patient who has a genetic susceptibility to a disease

48. Encounters for Other Specific Health Care (Z40–Z53) • Z47, Orthopedic aftercare • Intended to describe particular services related to orthopedic care • Aftercare following joint replacement surgery • Encounter for removal of internal fixation device • Explantation of joint prosthesis when the joint must be removed because of an infection in the joint or other complication • Encounters for aftercare following surgical amputation, scoliosis surgery, or other specified orthopedic care

49. Encounters for Other Specific Health Care (Z40–Z53) • Z49, Encounter for care involving renal dialysis • Main reason for the encounter is preparatory care for renal dialysis • Specifically fitting and adjustment of extracorporeal dialysis catheter or peritoneal dialysis catheter • Note appears under category Z49 to “code also associated end-stage renal disease (N18.6)”

50. Encounters for Other Specific Health Care (Z40–Z53) • Z51, Encounter for other aftercare • Admission or encounters for antineoplastic radiotherapy, antineoplastic chemotherapy and immunotherapy; palliative care and other specified aftercare • Z51.0, radiation therapy and Z51.1, chemotherapy are first-listed codes followed by the diagnosis code when the patient’s encounter is solely to receive radiation therapy or chemotherapy