ICD-10-CM Chapter 12,Z codes,13 Symptoms, Signs, and Ill-Defined Conditions – Flashcards

Sign

Symptom

Z77-Z99

R57.1

Z13.820

First Listed Diagnosis. Correct! Principal Diagnosis. ********* Primary Diagnosis. All of the above.

Cough Correct! Hematuria ********* Shortness of Breath Fever

False

False

R06.00

R10.30 If the patient is an outpatient , a diagnosis described as possible, probable, likely or similar phrasing is not coded as an established diagnosis.

R01.1 Look up Murmur in the Disease Index.

Z00.129 Look in the disease index under examination, child

Z45.010 Go to "removal" in the disease index, then cardiac pulse generator. If you chose to go to the main term "encounter", you will see a "see also" instructional note directing you to the main term removal. Since there is not a subterm for Cardiac device, you must follow the instructional note.

Z82.3 Find the main term, history, in the index. Then find the subterm family and the sub-subterm stroke.

M51.36 If the patient is an inpatient , a diagnosis described as possible, probable, likely or similar phrasing is considered to be an established diagnosis. Also, when determining if a symptom should be coded as an additional diagnosis, the coder must consider whether or not the symptom is an integral part of the definitive diagnosis or if there is a definitive diagnosis related to the symptom identified.

Codes for factors influencing health status and contact with health services.( Z00-Z99)

Care focused on the management of pain and other symptoms of patients who are in the terminal phase of an illness. Code Z51.5, Encounter for palliative care, is used to classify admissions or encounters for comfort care, end-of-life care, hospice care, and terminal care for terminally ill patients. This code may be used in any health care setting.

Codes for external causes to provide information for injury research and evaluation of injury prevention strategies.( V00-Y99)

Continued care during the healing phase or long term care due to the consequences of a disease.

Certain Z codes are designated as the principal ( or first listed) diagnosis in specific situations others are assigned as additional codes when it important to indicate a history, status, or problem that may effect health care. Some Z codes can be used as either the principal ( or first listed) diagnosis or as an additional code.

These are assigned as additional codes to indicate how the injury or health condition happened (cause), the intent (unintentional or accidental; intentional, such as suicide or assault), the place where the event occurd, the activity of the patient at the time of the event, and the person's status( Ex, civilian or military)

The following key main terms are used in the Alphabetic Index for Z codes: Admission Examination History Observation Aftercare Problem Status The Tabular List for Z codes follows immediately after the External Causes of Morbidity (V00-Y99) section in the Tabular List.

External cause of morbidity codes are not used to report the intent for poisonings, toxic effects, adverse effects, or underdosing of drugs. ICD-10-CM classifies these conditions using codes in categories T36-T65, which combine the substances involved with the external cause.

Z codes are used as principal (or first-listed) diagnosis to indicate: That a person with a resolving disease or injury or a chronic condition is being seen for specific aftercare. That the patient is seen for the sole purpose of special therapy. That a person not currently ill is encountering the health service for a specific reason. The birth status of newborns.

Z codes are used as additional diagnosis codes to indicate: That a patient has a history, health status, or other problem that is not in itself an illness or injury but may influence patient care. Exception: These Z codes can be listed first if the history itself is the reason for admission or encounter: Z85.- Personal history of malignant neoplasm Z86.6- Personal history of diseases of nervous system and sense organs Z80-Z84 Family history The outcome of delivery for obstetric patients.

Do not assign when treatment is directed at a current acute disease. Exceptions: Used when the initial treatment of a disease has been completed but the patient requires continued care during the healing phase or for long-term consequences of the disease. Encounters for antineoplastic chemotherapy and immunotherapy (Z51.1-) or radiotherapy (Z51.0). When the encounter is for the purpose of more than one type of antineoplastic therapy (e.g., radiation and chemotherapy), both codes are assigned and either can be sequenced first.

The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate seventh character for subsequent encounter (e.g., "D," "G," "K," or "P" for fractures).

Aftercare codes are generally listed first to explain the specific reason for the encounter. Occasionally, they can be used as additional codes when aftercare is provided during an encounter for treatment of an unrelated condition but no applicable diagnosis code is available. Aftercare codes should be used in conjunction with any other aftercare or diagnosis code(s) to provide better detail on the specifics of an aftercare visit, unless otherwise directed by the classification. The sequencing of multiple aftercare codes depends on the circumstances of the encounter. Certain aftercare Z codes need a secondary diagnosis code to describe the resolving condition or sequelae. Other aftercare Z codes include the condition in the code title.

When the patient is admitted because of a complication of previous care, the appropriate code from the main classification is assigned rather than the aftercare Z code. These codes should be reported along with any other aftercare codes or other diagnosis codes to provide more detail regarding an aftercare visit.

A code from category Z08, Z09, or Z39 is assigned as the principal diagnosis or reason for encounter when a patient is admitted for the purpose of surveillance after the initial treatment of a disease or injury has been completed. If a recurrence, extension, or related condition is identified, the code for that condition is assigned as the principal diagnosis rather than a code from category Z08, Z09, or Z39. 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.

A code from category Z03, Encounter for medical observation for suspected diseases and conditions ruled out, or category Z04, Encounter for examination and observation for other reasons, is assigned when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study but, after examination and observation, is ruled out. Categories Z03 and Z04 are also for use for administrative and legal observation status. Outpatient referral for surveillance or for further diagnostic studies does not contradict the use of a code from these categories. The observation codes are not used if an injury or illness, or any signs or symptoms related to the suspected condition, are present. Instead, the diagnosis or symptom code is used. When a related diagnosis is established, the code for that condition is assigned instead of a code from category Z03. Codes from category Z05 are used for observation and evaluation of a newborn within the neonatal period for suspected condition, ruled out. For persons with a feared complaint in whom no diagnosis is made, assign code Z71.1. A code from categories Z03-Z04 can be assigned only as the principal diagnosis or reason for encounter, never as a secondary diagnosis. A code from categories Z03-Z04 is ordinarily assigned as a solo code, with two exceptions: When a chronic condition requires care or monitoring during the stay, a code for that condition can be assigned as an additional code. When admission is for the purpose of ruling out a serious injury, such as concussion, codes for minor injuries such as abrasions or contusions may be assigned as additional codes. This exception is based on the fact that such minor injuries in themselves would not require hospitalization.

A code from categories Z03-Z04 can be assigned only as the principal diagnosis or reason for encounter, never as a secondary diagnosis. A code from categories Z03-Z04 is ordinarily assigned as a solo code, with two exceptions: When a chronic condition requires care or monitoring during the stay, a code for that condition can be assigned as an additional code. When admission is for the purpose of ruling out a serious injury, such as concussion, codes for minor injuries such as abrasions or contusions may be assigned as additional codes. This exception is based on the fact that such minor injuries in themselves would not require hospitalization.

Codes from subcategory Z03.7, Encounter for suspected maternal and fetal conditions ruled out, are generally assigned as the principal or first-listed diagnosis. The Z03.7 codes may be listed as secondary codes when there are multiple encounters on the same day and the medical records for the encounters are combined. Use codes from subcategory Z03.7 in very limited circumstances on the maternal record for a suspected maternal or fetal condition that is ruled out during that encounter. If the condition is confirmed, code the condition instead. Do not use Z03.7 codes if an illness or any signs or symptoms related to the suspected condition or problem are present. Instead, code the diagnosis/symptom. Other codes may be used in addition to subcategory Z03.7, but only if they are unrelated to the suspected condition being evaluated.

If a patient is admitted after a period in the outpatient observation unit for further evaluation unrelated to surgery, use as the principal diagnosis: The condition that provided the original reason for the outpatient observation. If a patient is admitted to an observation unit for a medical condition, and the medical condition worsens or does not improve, and the patient is admitted, use as the principal diagnosis: The medical condition that led to the hospital admission.

A code from category Z01 Is assigned as the reason for encounter only when no problem, diagnosis, or condition is identified as the reason for the examination. Z01 codes are rarely appropriate for inpatient coding and never assigned as secondary or additional codes.

Preoperative evaluations may involve a variety of ancillary tests. Assign one of the following codes with additional codes for the condition for which surgery is planned and for any findings related to the preoperative evaluation: Z01.810 Encounter for preprocedural cardiovascular examination Z01.811 Encounter for preprocedural respiratory examination Z01.812 Encounter for preprocedural laboratory examination Z01.818 Encounter for other preprocedural examination Z01.83 Encounter for blood typing

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. If no abnormal findings were identified during the examination but the encounter is being coded before test results are back, it is acceptable to assign the code for "without abnormal findings." When assigning a code for "with abnormal findings," an additional code(s) should be assigned to identify the specific abnormal finding(s). An examination with abnormal findings refers to a condition/ diagnosis that is newly found, or a change in severity of a chronic condition, during a routine physical exam.

Codes from categories Z11-Z13 are assigned to tests performed to identify a disease or disease precursors for early detection and treatment for those who test positive. Screening is performed on apparently well individuals who present no signs or symptoms relative to the disease. If a screening examination identifies pathology: The code for the reason for the test (namely the screening code from categories Z11-Z13) is assigned as the principal diagnosis or first-listed code. This code is followed by a code for the pathology or condition found during the screening exam.

Categories Z85-Z92 Indicate personal history of a previous condition. Do not assign if the condition is still present or still under treatment, or if a complication is present. Categories Z80-Z84 Indicate family history. May be assigned when the family history is the reason for examination or treatment. Categories Z88-Z99 Indicate the patient has a continuing condition or health status that may influence care. For example: tracheostomy (Z93.0), colostomy (Z93.3), cardiac pacemaker (Z95.0), or aortocoronary bypass graft (Z95.1).

Status codes indicate that a patient is a carrier of a disease, has the sequelae or residual of a past disease or condition, or has another factor influencing a person's health status. Z codes indicating status are redundant when the diagnosis code itself indicates that the status exists. The diagnostic statement "status post" most often refers to an earlier surgery, injury, or previous illness and usually has no significance for the episode of care. No code for the condition is assigned in this case. A personal history code can be assigned if desired. History codes vs. status codes: History—Problem no longer exists. Status—Condition is present.

Codes from categories Z55 through Z65 are used to indicate certain problems that may affect the patient's care or prevent satisfactory compliance with the recommended regimen. Examples of situations that can affect a patient's compliance are housing problems, social maladjustment, and economic or job concerns.

Category Z79 is used to indicate a patient's continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use. Codes are assigned if the patient is receiving a medication for an extended period. An additional code is assigned for the condition for which the medication is prescribed. Do not assign a Z79 code when the medication is prescribed to treat an acute illness or injury and is being given for a brief period of time (e.g., antibiotics to treat bronchitis). Do not use Z79 codes for detoxification or maintenance programs in patients with drug dependence.

Code Z51.81 is used to report encounters for therapeutic drug monitoring. If the drug being monitored is one that the patient has been receiving on a long-term basis, a code from category Z79 should be added. Coding guidelines do not provide a definition or time frame for long-term drug therapy.

History, status, and problem codes ordinarily cannot be used as the principal diagnosis or reason for encounter. Exceptions: Codes from categories Z85-Z87 (except subcategory Z87.7) Code Z91.81 Codes from categories Z80-Z84 These codes can be used as additional codes for any patient regardless of the reason for the encounter, but they are ordinarily assigned only when the history, status, or problem has some significance for the episode of care.

Genetic susceptibility refers to a genetic predisposition for contracting a disease. It is important to distinguish susceptibility from carrier state. An individual who is a carrier of a disease is able to pass it on to an offspring. Codes from category Z15 should not be used as principal or first-listed codes.

Patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter: Code the current condition first, followed by the Z15.- code. Patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists: Assign a follow-up code first, followed by the personal history (Z85.- to Z87.-) and genetic susceptibility codes (Z15.-). The purpose of the encounter is genetic counseling associated with procreative management: Assign code Z31.5, Encounter for genetic counseling, first, followed by a code from category Z15. Assign additional codes for any applicable family or personal history.

The guidelines contain a list of Z codes that may only be assigned as the principal/first-listed diagnosis, except: When there are multiple encounters on the same day and the medical records for the encounters are combined, or When there is more than one Z code that meets the definition of principal diagnosis. These codes should not be reported if they do not meet the definition of principal or first-listed diagnosis.

Z48.01

Z83.71

Z95.1

Z43.1

Z45.010

Z79.01

Z99.11

Z51.5

Z12.31

Z51.0

Z91.130

Z48.02

Symptoms, Signs, and Ill-Defined Conditions

Objective evidence of disease that can be observed by the examining physician.

Subjective observation reported by the patient but not confirmed objectively by the physician.

Signs and symptoms are classified in two ways in ICD-10-CM: Those that point to more than one disease or system, or that are of unexplained etiology, are classified to chapter 18 of ICD-10-CM. Those that point to a specific diagnosis have been assigned to a category in other chapters of ICD-10-CM.

Codes for symptoms, signs, and ill-defined conditions from chapter 18 of ICD-10-CM cannot be used as principal diagnoses or reasons for outpatient encounters when related diagnoses have been established.

Diagnoses described as possible, probable, and so on at the time of discharge are treated differently depending on whether the patient is an inpatient or outpatient. If patient is an inpatient, the diagnosis is considered to be an established diagnosis. If patient is an outpatient; the diagnosis is not considered to be an established diagnosis. If there is not an established diagnosis, only whatever symptoms or signs that are available at the highest level of certainty are assigned.

Symptom codes from chapter 18 can be correctly designated as the principal diagnosis when no related condition is identified and the symptom is the reason for the encounter. In this instance, a code from chapter 18 of ICD-10-CM is assigned as the principal diagnosis even though other unrelated diagnoses may be listed. Other situations in which chapter 18 codes can be appropriately used as the principal diagnosis for an inpatient admission: Presenting signs or symptoms are transient, and no definitive diagnosis can be made. The patient is referred elsewhere for further study or treatment before a diagnosis is made. A more precise diagnosis cannot be made for any other reason. The symptom is treated in an outpatient setting without the additional workup required to arrive at a more definitive diagnosis.Provisional diagnosis of a sign or symptom is made for a patient who fails to return for further investigation or care. A residual late effect is the reason for admission, and the Alphabetic Index directs the coder to an alternative sequencing. Generally speaking, symptom codes classified to other chapters are not designated as principal diagnoses when a related condition has been identified. The symptom can be designated as the principal diagnosis, however, when the patient is admitted for the sole purpose of treating the symptom and there is no treatment or further evaluation of the underlying disease.

Outpatient encounters do not ordinarily permit the type of study that results in an established diagnosis, and treatment is often directed at relieving symptoms rather than treating the underlying condition. The highest level of certainty is reported as the reason for encounter for outpatients. This often means that a symptom code is assigned as the reason for the encounter.

Codes from chapter 18 are assigned as secondary codes only when the symptom or sign is not integral to the underlying condition, unless otherwise instructed by the classification, and when its presence makes a difference in the severity of the patient's condition and/or the care given. Codes from chapter 18 are not assigned when they are implicit in the diagnosis or when the symptom is included in the condition code. ICD-10-CM contains combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. Additional codes should not be assigned for the symptoms.

Categories R90 through R97 in chapter 18 are provided for coding nonspecific abnormal findings. It is rarely appropriate to assign codes from these categories for acute inpatient hospital care. These codes are assigned only when: The physician has not been able to arrive at a definitive related diagnosis and lists the abnormal finding itself as a diagnosis, and The condition meets the Uniform Hospital Discharge Data Set (UHDDS) criteria for reporting of other diagnoses. If the coder notes clinical findings outside the normal range but no related diagnosis is stated: Review record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given. Ask the physician whether a code should be assigned.

Scale for assessing the degree of consciousness, especially after a head injury. Scoring determined by three factors: Amount of eye opening, Verbal responsiveness, and Motor responsiveness. The test score can function as an indicator for certain diagnostic tests or treatments and for predicting the duration and ultimate outcome of coma.

Codes in subcategory R40.2, Coma, can be used in combination with traumatic brain injury or acute cerebrovascular disease codes, or sequelae of cerebrovascular disease codes. The codes are primarily for use by trauma registries but may be used in any setting where this information is collected. Codes may also be used to assess the status of the central nervous system for other nontrauma conditions, such as monitoring patients in the intensive care unit, regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s). One code from each subcategory (amount of eye opening, verbal responsiveness, and motor responsiveness) is needed to complete the scale. The seventh character indicates when the scale was recorded (e.g., in the field, at arrival to emergency department, at hospital admission, 24 hours or more after hospital admission, or unspecified time). The seventh character should match for all three codes. At a minimum, the initial score documented upon presentation at the facility should be recorded. May be a score from the emergency medicine technician or documented in the emergency department. A facility may choose to capture multiple Glasgow coma scale scores, if desired. When only total score is documented: Assign a code from R40.24-, Glasgow coma scale, total score. When individual score(s) is(are) documented: Assign one code from each subcategory R40.21- through R40.23-. When Glasgow coma scale score is not documented or only a partial score is reported: Assign code R40.244.

Similar to the codes for Glasgow coma scale individual scores (subcategories R40.21-, R40.22-, and R40.23-), codes for the total score (subcategory R40.24-) require a seventh-character to indicate when the scale was recorded.

National Institutes of Health stroke scale (NIHSS) is a clinical assessment tool to evaluate and document neurological status in acute stroke patients. Used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Subcategory R29.7- is used to report NIHSS scores. Codes are used as secondary codes. Acute cerebral infarction (I63-) should be coded as the first-listed diagnosis.

Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstances when a patient who has already died is brought into an emergency department or other health care facility and is pronounced dead on arrival. This code should not be used to represent the discharge disposition of death.

R30.0

J11.1

R31.0

N39.0

R59.0

R73.02

R42 R51 R11.0

R55

I20.9

F45.8

I70.262

R04.0 2Y41x5z

I78.0

K85.9 K81.9

R53.82

B34.9

R50.9 R51

R73.03