Chapter Contact With Health Services – Flashcards

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. Codes in this chapter are referred to as Z codes. Z codes are reported when the patient is not sick and presents for specific care (eg, routine physical, screening mammogram) to report a specific type of care (eg, physical therapy, chemotherapy) or to identify the status of the patient that may affect the management of care (eg, family history of colon cancer). A Z code is always the first listed code to report a newborn birth status. Z codes can be used in any healthcare setting. They can be sequenced as primary or secondary codes. There is a list of all the Z codes that can only be reported as the first listed diagnosis. The complete list can be found in Section I.C.21.c.16., Z Codes That May Only be Principal/First Listed Diagnosis, in the Official Coding Guidelines. Z codes are divided into sixteen categories. Using the titles of the following Z categories is helpful when locating terms in the Alphabetic Index.

A patient can be exposed to a communicable disease and not develop signs or symptoms. Although the patient is not sick or showing any signs or symptoms, she often will need to be examined, or require a screening test or prophylactic treatment. For example, if a patient is exposed to tuberculosis, a chest X-ray will be ordered. These Z codes are found under the main term Exposure in the Alphabetic Index listed under category code Z20, Category Z77 indicates contact with suspected exposures hazardous to health.

The code for inoculations and vaccinations is Z23. This code indicates a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes (discussed later in the curriculum) are required to identify the actual administration of the injection and the type(s) of immunizations given. When a patient is seen for a preventive visit or other visit, and receives an inoculation as part of the visit, Z23 is listed as an additional code. Codes in category Z28 are reported when a vaccination(s) is not carried out. The code is selected on the reason why the vaccination(s) was not carried out.

Status codes indicate 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. Examples of codes found in this category include a patient who had a transplant, medical device, asymptomatic HIV, and use of anticoagulants. The status Z code categories are listed in Section Guideline I.C.21.c.3. Status codes are distinct from history codes. History codes indicate that the patient no longer has the condition. When a patient has a complication of a disease, illness, or surgical procedure, and the complication code indicates the condition (for example subcategory T86.2 Complications of Heart Transplant, the status code is not reported. Indicating the patient is status heart transplant does not provide any further information than provided with T86.2.

There are two types of history: Personal history and family history. Family history is important to report because some diseases have a genetic predisposition. For example, female patients with a family history of breast cancer are at a higher risk for developing breast cancer. Family history codes are found in the Alphabetic Index under History/family (of). Personal history is reported if the patient no longer has the disease. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. Personal history codes are found in the Alphabetic Index under History/personal (of). The history Z code categories are listed in Section Guideline I.C.21.c.4.

There are many screening tests performed to identify problems before a patient starts to exhibit signs or symptoms. The purpose of preventive medicine is to identify potential health problems before they become severe. For example, colonoscopies are performed as a screening test for colon cancer when a patient turns 50-years-old. The proper diagnosis code is Z12.11 Encounter for screening for malignant neoplasm of colon. To locate screening codes, look for Screening in the Alphabetic Index and the subterm for the condition for which the screening occurs. 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). A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination. The screening Z code categories are listed in Section Guideline I.C.21.c.5.

Codes for observation are not used if a specific disease or injury is being observed. In that case you would report the code to identify the injury. These codes are used only when the suspected condition being observed is ruled out. For example, if a child is suspected to have ingested household cleaner, the child would be observed for reactions. If the child does not develop any symptoms, report a code Z03.6 Encounter for observation for suspected toxic effect from ingested substance ruled out. The observation Z code categories are: - Z03 Encounters for Medical Observation For Suspected Diseases And Conditions Ruled Out - Z04 Encounter for Examination And Observation for Other Reasons - Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out These codes are used in rare circumstance. Codes for observation are reported as the primary code when used with the exception of code Z05 which may be first listed or as an additional code sequenced after a code from category Z38.

Aftercare codes are used to report the confirmed care the patient receives after the acute phase of treatment. Aftercare codes are reported during the healing or recovery phase. Do not report aftercare codes if active treatment is performed for the condition. Codes from other ICD-10-CM chapters may be required to report the patient's condition for the encounter. 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 7th character. The aftercare Z code categories are listed in Section Guideline I.C.21.c.7.

Codes from this category are used to indicate the surveillance of a condition that has healed fully and no longer exists. Do not confuse follow-up care with aftercare. Aftercare codes are reported for encounters required during the healing phase of a condition. Follow up is reported when the condition has fully healed. A provider may require a patient to come to the office following treatment to make sure the patient responded. For example; a patient with chronic tonsillitis is seen to make sure the condition is fully resolved following a six month course of antibiotics. When the patient is seen, the provider documents the tonsillitis is resolved. The follow-up Z code categories are listed in Section Guidelines I.C.21.c.8.

Category Z52 is reported for a patient who donates tissue or blood to another patient. This code is not used for organs harvested from cadavers or for self donations. For example, prior to surgery a patient may donate his or her own blood in case he or she needs a blood transfusion as a result of surgery. In this example, do not report a code from category Z52. Instead, report the code for the reason for the surgery.

Z codes are reported when a patient or family member receives counseling following an illness or injury, or when support is required in coping with family or social problems. There are counseling codes for genetic counseling, contraception, family problems (eg, marital,. substance abuse in the family, and victims of child abuse), and dietary counseling. The counseling Z code categories are listed in Section Guideline I.C.21.c.10.

Z codes are reported when a patient presents for a routine exam. Examples include well child preventative visits, routine gynecological exams, and preoperative clearance. Some of the codes for routine health examinations have an option for with or without abnormal findings. The code is selected based on the information known at the time of coding. If the provider orders a test during the examination, but results are not back, and no abnormal findings are mentioned, the option for without abnormal findings is reported. An abnormal finding is a condition the provider finds during that visit when examining the patient or an abnormal result from a test ¬at that visit. When the option for with abnormal findings is reported, additional codes are reported for the condition. The Z code categories for routine and administrative examinations are listed in Section Guideline ' I.C,21.c.13.

Patient's often see their medical provider for annual general medical examinations. During the examination, the provider may identify an abnormal finding. When this occurs, a code from subcategory Z00.0 for general medical examinations with abnormal findings is reported as the primary code. The abnormal findings are reported as additional codes. According to the ICD-10-CM guidelines, "An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physician examination."

Diagnostic Coding and Reporting Guidelines, for Outpatient Services is described in section IV of the ICD-10-CM Official Guidelines for Coding and Reporting. These coding guidelines for outpatient diagnoses have been approved for use by hospitals/physicians in coding and reporting hospital based outpatient services and physician office visits. Review the following guideline sections for coding and reporting outpatient services.

- In the outpatient setting, the first listed diagnosis is used in lieu of principal diagnosis. - In determining the first listed diagnosis, the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines, take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List because this will lead to coding errors.

The appropriate code or codes from A00.00 through T88.9 and ZOO-Z99 must be used to identify diagnoses, signs, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.

For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient's condition, using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these situations.

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the physician. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes ROO-R99) contain many, but not all codes for symptoms.

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Classification of Factors Influencing Health Status and Contact with Health Services codes (Z00-Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

ICD-10-CM is composed of codes with three, four, five, six, or seven characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be subdivided further with use of additional characters, which provide greater specificity. A three-character code is to be used only if it is not further subdivided. Where further specificity is provided, additional characters must be assigned. A code is invalid if it has not been coded to the full number of characters (highest level of specificity) required for that code. See also the discussion under Section I, General Coding Guidelines, level of detail.

List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the ' services provided. List additional codes that describe any co-existing conditions.

Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis." Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as. symptoms, signs, abnormal test results, or other reason for the visit

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

Code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care, treatment, or management. Do not code, conditions treated prior to this encounter/visit that no longer exist. History codes (Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or Other-reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient' services provided during the encounter/visit. Codes for other diagnoses (eg, chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign 201.89 Encounter for other specified special examinations. The findings from diagnostic tests can be coded for outpatient services if they are interpreted by a physician and the final.report is available at the time of coding. Do not code related signs and symptoms as additional diagnoses. See section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services, K. Patients receiving diagnostic services only (Section IV.K.). This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

For patients receiving therapeutic services only during an 'encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (eg, chronic conditions) may be sequenced as additional diagnoses.

For patients receiving preoperative evaluations only, sequence a code from category Z01.81 Encounter for Pre-Procedural Examinations to describe the preoperative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preoperative evaluation.

For ambulatory surgery, code the diagnosis for which he surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding because it is the most definitive.

For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounters for Supervision of Normal Pregnancy is reported.