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Z codes and procedure

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Corresponding procedure code must accompany

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Category Z20, contact/exposure

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Used for patients who do not show any sign/symptom of a disease but are suspected to have been exposed to it

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Z77

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Indicates contact with and suspected exposures hazardous to health

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Contact/exposure codes

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May be used as a first-listed code to explain an encounter for testing or as a secondary code to identify a potential risk

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Z23, inoculations and vaccines

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Used with procedure codes May be a secondary code if inoculation is given as a routine part of preventive health care

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What status codes should not be used with

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diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code

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Encounters for weaning from a mechanical ventilator

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Assign a code from J96.1, Chronic respiratory failure, followed by Z99.11, Dependence on respiratory [ventilator] status

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Genetic carrier status

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Indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease Does not have disease and not at risk for developing disease

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Genetic susceptibility, Z15

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Indicates that a person has a gene that increases the risk of that person developing the disease Not used as principal/first-listed

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If the patient has the condition to which he/she is genetic susceptible and that condition is the reason for the encounter

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Sequence the code for the current condition first

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If the patient is being seen for follow-up after completed treatment for a condition and they are genetic susceptible and the condition no longer exists

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Follow-up code should be sequenced first followed by the appropriate personal history and genetic susceptibility codes

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If the purpose of the encounter is genetic counseling associated with procreative management,

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First-listed code should be Z31.5, Encounter for genetic counseling, followed by a code from Z15 with additional codes for any applicable family or personal history

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Z16, Resistance to antimicrobial drugs

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Sequence infection code first

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Z33.1, Pregnant state, incidental

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Secondary code

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Z78.1, Physical restraint status

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Not to be used if patient is temporarily restrained during a procedure

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

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Secondary code Applies even if they are still receiving treatment Condition for which required treatment sequenced first

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Z98.85, Transplanted organ removal status

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Not applied during actual removal

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Personal history

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Do not exist, no longer receiving treatment but has potential for recurrence

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Personal history can be used in conjunction with __.

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follow-up codes

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Family history codes can be used in conjunction with ___.

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screening codes

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Screening may be first-listed if ___.

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if the reason for the visit is for the screening exam

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Screening code not necessary if ___.

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Screening is inherent to a routine examination

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Condition discovered during screening

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Condition may be assigned as additional diagnosis

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Observation codes uses

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Very limited circumstances when a person is being observed for a suspected condition that is ruled out

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When not to use observation codes

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If an injury or illness or any signs or symptoms related to the suspected condition are present. In these cases the diagnosis/symptom code is used with the corresponding external cause code.

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Observation code sequencing

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PDX Additional codes may be used only if they are unrelated to the suspected condition being observed

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Codes from category Z03.7, encounter for suspected maternal and fetal conditions ruled out sequencing

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May be used as a first-listed or as an additional code assignment

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Codes from category Z03.7, encounter for suspected maternal and fetal conditions ruled out uses

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Very limited on a maternal record when an encounter is for a suspected maternal or fetal condition that is ruled out during that encounter Not used when condition confirmed (instead use condition code)

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Codes from category Z03.7, encounter for suspected maternal and fetal conditions not for use

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When an illness or any signs/symptoms related to the suspected condition or problem are present. Instead you should use the diagnosis/symptom code

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Additional codes with category Z03.7, encounter for suspected maternal and fetal conditions

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May be used only if they are unrelated to the suspected condition being evaluated

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category Z03.7, encounter for suspected maternal and fetal conditions and encounters for antenatal screening of mother

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Not used together

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For encounters for suspected fetal condition that are inconclusive following testing and evaluation

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Use appropriate O code

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Aftercare visit codes uses (encounters)

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When initial treatment of a disease has been performed and the patient requires continued care during healing or recovery phase or for the long-term consequences of the disease

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Aftercare Z code should not be used __.

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if treatment is directed at a current, acute disease. Instead, the diagnosis code should be used. aftercare of injuries

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Z51.0, Encounter for antineoplastic radiation therapy

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First listed followed by diagnosis code when a patient's encounter is solely to receive radiation therapy

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Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy

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First listed followed by diagnosis code when a patient's encounter is solely to receive therapy

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Aftercare of injury

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Assign the acute injury code with the appropriate 7th character for subsequent encounter

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Aftercare code sequencing

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First listed or as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable

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Sequencing of multiple aftercare codes

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Depends on circumstances of encounter

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Follow-up code uses

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Explains continuing surveillance following completed treatment of a disease, condition, or injury Implies condition is fully treated and no longer exists

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Follow-up codes may be used in conjunction with ___.

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History codes with follow-up sequenced first

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Should a condition be found to have recurred on the follow-up visit

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Diagnosis code used in place of follow-up code

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Who Z52, Donors of organs and tissues is for

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Living donors, not for self or cadaveric donations

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Z34, Encounter for supervision of normal pregnancy

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Always first-listed and not used with any other OB codes

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Z37, outcome of delivery

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Included on maternal delivery records Always a secondary code

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What is to be used to determine the weeks of gestation for inpatient admissions that encompass more than one gestational week

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Date of the admission

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When encounters for exams should not be used

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If the exam is for diagnosis of a suspected condition

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During a routine exam, a diagnosis or condition is discovered

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Z code encounter followed by additional code for diagnosis

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When pre-existing, chronic conditions, and history codes can be included with z code for routine and administrative examination

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If the examination is for administrative purposes and not focused on any particular condition

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Prophylactic organ removal

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Code first encounter for prophylactic surgery followed by appropriate code(s) to identify the associated risk factor (genetic susceptibility or family history)

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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

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Prophylactic surgery encounter Code for malignancy should also be assigned

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When Z40, Encounter for prophylactic surgery should not be assigned

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If the patient is having organ removal for treatment of a malignancy

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Nonspecific Z codes in inpatient setting

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Very little use

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Nonspecific Z codes in outpatient setting

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Limited to instances when there is no further documentation to permit more precise coding

RHIT: ICD-10-CM Guidelines: Chapter 21 – Z codes – Flashcards

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