Chapter 21 Factors influencing health status and contact with health services Categories Z00-Z99 Official Coding Guidelines: Section 1.c.21. p.

Transcription

1 Chapter 21 Factors influencing health status and contact with health services Categories Z00-Z99 Official Coding Guidelines: Section 1.c.21. p. 75 6/10/2010 1

2 Z00 Z13 Persons encountering health services for examination and investigation Z14 Z15 Genetic carrier and genetic susceptibility to disease Z16--Infection with drug-resistant microorganisms Z17 --Estrogen receptor status 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 6/10/2010 2

3 Z55 Z65Persons with potential health hazards related to socioeconomic and psychosocial circumstances Z66 Do not resuscitate (DNR) status Z67 Blood Type Z69 Z76 Persons encountering health services in other circumstances Z79 Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status 6/10/2010 3

4 Represent reason for encounter Corresponding procedure code identifies any procedure performed. Used when circumstances other than a disease, an injury, or an external cause classifiable to categories A00 through Y89 are reason for encounter. Can be used as a first listed diagnosis for inpatients or a secondary diagnosis Some Z codes may only be used as PDX. 6/10/2010 4

5 1. When a person who may or may not be sick encounters health services for specific purpose receive limited care or service for current condition donate organ or tissue, receive a prophylactic vaccination, discuss problem which is in itself not a disease or injury 2. When some circumstance or problem is present that influences the person s health status but is not in itself a current illness or injury 6/10/2010 5

6 Indicates contact with, and suspected exposure, to communicable disease Used when patients show no sign/symptom of disease Are suspected to have been exposed by contact with infected individual or in area where disease is epidemic May be used as first listed diagnosis Explain encounter for testing Secondary code to identify potential risk. 6/10/2010 6

7 Category Z23 Patient to receive prophylactic immunization against a disease Procedure codes identify actual administration of injection & type(s) of immunizations given May be used as secondary diagnosis when inoculation is part of routine preventive visit or well-baby care 6/10/2010 7

8 Indicates patient is a Carrier Has sequelae or residual of past condition/disease Presence of prosthetic or mechanical device Status may affect course of treatment & its outcome Not used if diagnosis code includes information provided by status code Z94.1 Heart transplant status T86.2 Complications of heart transplant 6/10/2010 8

9 Z14 Genetic Carrier Does not have disease but can pass to offspring Z15 Genetic Susceptibility to Disease Person has gene that increases risk for disease Not used as first listed code If person has the disease, code disease If seen for follow up after completed treatment & condition no longer exists, sequence F/U code first, followed by personal HX & genetic susceptibility If encounter for genetic counseling, Z31.5 is first listed followed by Z15 category code. Z16 Infection with drug-resistant organisms Sequence infection code first Z 17 Estrogen Receptor Status 6/10/2010 9

10 Z 21 Asymptomatic HIV Infection Status Tested positive for HIV but not signs/symptoms Cannot report in California Z 22 Carrier of Infectious Disease Z28.3 Under-immunization Status Z33.1 Pregnant State Incidental Secondary code when pregnancy is in no way complicating reason for visit. Z66 Do not resuscitate Z67 Blood Type 6/10/

11 Z67 Blood type Z67.1 Type A blood Z67.10 Type A blood, Rh positive Z67.11 Type A blood, Rh negative Z67.2 Type B blood Z67.20 Type B blood, Rh positive Z67.21 Type B blood, Rh negative Z67.3 Type AB blood Z67.30 Type AB blood, Rh positive Z67.31 Type AB blood, Rh negative Z67.4 Type O blood Z67.40 Type O blood, Rh positive Z67.41 Type O blood, Rh negative Z67.9 Unspecified blood type Z67.90 Unspecified type, Rh positive Z67.91 Unspecified type, Rh negative 6/10/

12 Z68 Body Mass Index Z74.01 Bed Confinement Status Z76.82 Awaiting Organ Transplant Status Z78 Other Specified Health Status Z79 Long Term Drug Therapy Patient s continuous use of prescribed drug for longterm treatment of condition/prophylactic use Prevention of deep vein thrombosis Coumadin Treatment of chronic condition (arthritis) Disease requiring lengthy course of treatment (cancer) Not for medication administered for short period to treat acute illness/injury (antibiotics for acute bronchitis) Not for those with addictions to drugs Not for detoxification or maintenance programs to prevent withdrawal 6/10/

13 Z88 Allergy Status to drugs, medicaments & biological substances Z89 Acquired absence of limbs Z90 Acquired absence of organs, NEC Z91.0 Allergy Status, other than to drugs & biological substances Z92.82 Status post administration of tpa (rtpa) in a different facility within last 24 hours prior to admission to a current facility. Used if patient still receiving tpa at time they are received into the current facility Condition for which tpa is administered sequenced first Used only by the receiving facility 6/10/

14 Z93 Artificial Opening Status Z94 Transplanted Organ and tissue status Z95 Presence of cardiac & vascular implants and grafts Z96 Presence of other functional implants Z97 Presence of other devices Z98 Other post-procedural states Z98.85, Transplanted organ removal status Transplanted organ has been previously removed. Not be assigned for the encounter when organ removed. Use complication code necessitating removal Z99 Dependence on Enabling machines & devices 6/10/

15 Categories Z89-Z90 and Z93-Z99 Used only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent 6/10/

16 Personal history codes Past medical condition that no longer exists and is not receiving any treatment, has potential for recurrence, and may require continued monitoring. Used in conjunction with follow-up codes Can code both history of primary and metastatic sites Family history codes A family member(s) has had a particular disease that causes patient to be at higher risk of also contracting the disease. Used in conjunction with screening codes to explain need for test or procedure. Acceptable on any medical record History of illness, even if no longer present, is important information that may alter type of treatment ordered. 6/10/

17 Testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram). If patient has some sign or symptom, then it is a diagnostic examination, not a screening. Code sign or symptom is used to explain the reason for the test. May be first listed code if the reason for the visit is specifically the screening exam. Used as an additional code if the screening is done during an office visit for other health problems. Not necessary if the screening is inherent to a routine examination, pap smear done during a routine pelvic examination. Condition discovered during the screening are coded as an additional diagnosis. 6/10/

18 The Z code indicates screening exam is planned. Procedure code will confirm screening was performed. Z11 Encounter for screening for infectious and parasitic diseases Z12 Encounter for screening for malignant neoplasms Z13 Encounter for screening for other diseases and disorders Z36 Encounter for antenatal screening for mother 6/10/

19 Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Used when person is observed for suspected condition that is ruled out. Not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. the diagnosis/symptom code is used with the corresponding external cause code. Used as principal diagnosis only. Additional codes may be used but only if they are unrelated to the suspected condition being observed. 6/10/

20 Z03.7 Encounter for suspected maternal and fetal conditions ruled out, May either be used as a first listed or as an additional code assignment For use in very limited circumstances on a maternal record Encounter is for suspected maternal or fetal condition that is ruled out during that encounter A maternal or fetal condition may be suspected due to an abnormal test result Codes are not used when condition is confirmed. Code confirmed condition Not used if illness or any signs/symptoms of suspected condition or problem are present. In such cases, the diagnosis/symptom code is used. 6/10/

21 Cover situations when initial treatment of disease has been performed and patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Not used if treatment is directed at a current, acute disease. Use diagnosis code in these cases. Exceptions to this rule are Z51.0, Encounter for antineoplastic radiation therapy Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. 6/10/

22 These codes are first listed, followed by the diagnosis code when a patient s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm. If the reason for the encounter is more than one type of antineoplastic therapy, code Z51.0 and a code from subcategory Z51.1 may be assigned together, in which case one of these codes would be reported as a secondary diagnosis. The aftercare Z codes are not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the 7th character D (subsequent encounter). The aftercare codes are generally first listed to explain t 6/10/

23 First listed to explain specific reason for encounter. May be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. Closure of a colostomy during an encounter for treatment of another condition. Should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. Should a patient receive multiple types of antineoplastic therapy during the same encounter, code Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy, may be used together on a record. 6/10/

24 Sequencing of multiple aftercare codes depends on circumstances of the encounter. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings. 6/10/

25 Status Z codes may be used with aftercare Z codes to indicate nature of the aftercare. For example code Z95.1, Presence of aortocoronary bypass graft Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed. A status code is not used when the aftercare code indicates the type of status, Z43.0, Encounter for attention to tracheostomy, with Z93.0, Tracheostomy status. 6/10/

26 Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z43 Encounter for attention to artificial openings Z44 Encounter for fitting and adjustment of external prosthetic device Z45 Encounter for adjustment and management of implanted device Z46 Encounter for fitting and adjustment of other devices Z47 Orthopedic aftercare Z48 Encounter for other postprocedural aftercare Z49 Encounter for care involving renal dialysis Z51 Encounter for other aftercare 6/10/

27 Used to explain continuing surveillance following completed treatment of a disease, condition, or injury. Imply condition has been fully treated and no longer exists. Do not confused with aftercare codes, or injury codes with 7th character D, that explain ongoing care of a healing condition or its sequelae. May be used in conjunction with history codes to provide full picture of healed condition and its treatment. The follow-up code is sequenced first, followed by the history code. 6/10/

28 A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, code for the condition assigned as an additional diagnosis. Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z39 Encounter for maternal postpartum care and examination 6/10/

29 Z52, Donors of organs and tissues, Used for living individuals who are donating blood or other body tissue. These codes are only for individuals donating for others, not for self-donations. Not used to identify cadaveric donations. 6/10/

30 Used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. Not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment. Z30.0- Encounter for general counseling and advice on contraception Z31.5 Encounter for genetic counseling Z31.6- Encounter for general counseling and advice on procreation Z32.2 Encounter for childbirth instruction 6/10/

31 Z32.3 Encounter for childcare instruction Z69 Encounter for mental health services for victim and perpetrator of abuse Z70 Counseling related to sexual attitude, behavior and orientation Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified Z76.81 Expectant mother prebirth pediatrician visit 6/10/

32 Used when none of the problems or complications included in the codes from the Obstetrics chapter exist a routine prenatal visit or postpartum care Z34 Encounter for supervision of normal pregnancy always first listed and not used with any other code from the OB chapter. 6/10/

33 Z37 Outcome of delivery included on all maternal delivery records. always a secondary code Is not used on the newborn record. Z codes for family planning (contraceptive) or procreative management and counseling should be included on an obstetric record either during the pregnancy or the postpartum stage, if applicable. Z33.2, Encounter for elective termination of pregnancy category excludes spontaneous abortion 6/10/

34 Z30 Encounter for contraceptive management Z31 Encounter for procreative management Z32.2 Encounter for childbirth instruction Z32.3 Encounter for childcare instruction Z33 Pregnant state Z34 Encounter for supervision of normal pregnancy Z36 Encounter for antenatal screening of mother Z37 Outcome of delivery Z39 Encounter for maternal postpartum care and examination Z76.81 Expectant mother prebirth pediatrician visit 6/10/

35 See Section I.C.16. Newborn (Perinatal) Guidelines, for further instruction on the use of these codes. Z76.1 Encounter for health supervision and care of foundling Z00.1- Encounter for routine child health examination Z38 Liveborn infants according to place of birth and type of delivery 6/10/

36 Encounters for routine examinations, a general check-up, examinations for administrative purposes a pre-employment physical. Not used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. 6/10/

37 Pre-existing and chronic conditions and history codes may also be included as additional codes as long as examination is for administrative purposes and not focused on any particular condition. Some of the codes for routine health examinations distinguish between with and without abnormal findings. 6/10/

38 Code assignment depends on information known at time encounter is being coded. For example, if no abnormal findings were found 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 with abnormal findings, additional code(s) assigned to identify the specific abnormal finding(s). Pre-operative examination & pre-procedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given. 6/10/

39 Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z32.0- Encounter for pregnancy test 6/10/

40 Capture a number of other health care encounters that do not fall into one of the other categories. Identify the reason for the encounter Report additional codes that provide useful information on circumstances that may affect a patient s care and treatment. 6/10/

41 Prophylactic removal of breasts due to a genetic susceptibility to cancer or a family history of cancer Principal or first listed code Code from category Z40, Encounter for prophylactic surgery, Followed by the appropriate codes to identify the associated risk factor (such as genetic susceptibility or family history). 6/10/

42 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, Code for the malignancy assigned in addition to a code from subcategory Z40.0, Encounter for prophylactic surgery for risk factors related to malignant neoplasms. Do not use Z40.0 code organ removal for treatment of a malignancy Removal of the testes for the treatment of prostate cancer. 6/10/

43 Z28 Immunization not carried out Z40 Encounter for prophylactic surgery Z41 Encounter for procedures for purposes other than remedying health state Z53 Persons encountering health services for specific procedures and treatment, not carried out Z55 Problems related to education and literacy 6/10/

44 Z56 Problems related to employment and unemployment Z57 Occupational exposure to risk factors Z58 Problems related to physical environment Z59 Problems related to housing and economic circumstances Z60 Problems related to social environment Z62 Problems related to upbringing 6/10/

45 Z63 Other problems related to primary support group, including family circumstances Z64 Problems related to certain psychosocial circumstances Z65 Problems related to other psychosocial circumstances Z72 Problems related to lifestyle Z73 Problems related to life management difficulty Z74 Problems related to care provider dependency Z75 Problems related to medical facilities and other health care 6/10/

46 Z76.0 Encounter for issue of repeat prescription Z76.3 Healthy person accompanying sick person Z76.4 Other boarder to healthcare facility Z76.5 Malingerer [conscious simulation] Z76.89 Persons encountering health services in other specified circumstances Z91.1- Patient s noncompliance with medical treatment and regimen Z91.89 Other specified 6/10/

47 Little justification for use in inpatient setting. Use in outpatient setting should be limited to those instances when there is no further documentation to permit more precise coding. Otherwise, any sign or symptom or any other reason for visit that is captured in another code should be used. Nonspecific Z codes/categories: Z02.9 Encounter for administrative examinations, unspecified Z04.9 Encounter for examination and observation for unspecified reason 6/10/

48 Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z33.2 Encounter for elective termination of pregnancy Z31.81 Encounter for male factor infertility in female patient Z31.82 Encounter for Rh incompatibility status Z31.83 Encounter for assisted reproductive fertility procedure cycle Z31.84 Encounter for fertility preservation procedure Z34 Encounter for supervision of normal pregnancy 6/10/

49 Z39 Encounter for maternal postpartum care and examination Z38 Liveborn infants according to place of birth and type of delivery Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z51.0 Encounter for antineoplastic radiation therapy Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy Z52 Donors of organs and tissues Except: Z52.9, Donor of unspecified organ or tissue Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child Z99.12 Encounter for respirator [ventilator] dependence during power failure 6/10/

50 Z44.0 Encounter for fitting and adjustment of artificial arm Z44.00 Encounter for fitting and adjustment of unspecified artificial arm Z44.001Encounter for fitting & adjustment of unspecified right artificial arm Z Encounter for fitting & adjustment of unspecified left artificial arm Z Encounter for fitting & adjustment of unspecified artificial arm, unspecified arm 6/10/

51 Z70 Counseling related to sexual attitude, behavior and orientation Z70.0 Counseling related to sexual attitude Z70.1 Counseling related to patient s sexual behavior and orientation Z70.2 Counseling related to sexual behavior and orientation of third party Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation Z70.8 Other sexual counseling Z70.9 Sex counseling, unspecified 6/10/

52 Z79 Long-term (current) drug therapy. Fourth characters identify drugs involved. Z79.0 Long-term (current) use of anticoagulants & antithrombotics/ antiplatelets Z79.1 Long-term (current) use of non-steroidal antiinflammatories Z79.2 Long-term (current) use of antibiotics 6/10/

53 Allergies to drugs, medicaments, and biological substances as well as to foods, insects, and non-medicinal substances. For example: Z88 Allergy status to drugs, medicaments and biological substances Z88.0 Allergy status to penicillin Z88.1 Allergy status to other antibiotic agents status Z88.2 Allergy status to sulfonamides status 6/10/

54 Z91 Personal risk-factors, not elsewhere classified Z91.0 Allergy status, other than to drugs and biological substances Z91.01 Food allergy status Z Allergy to peanuts Z Allergy to milk products Z Allergy to eggs Z Allergy to seafood, shellfish, octopus or squid ink Z Allergy to other foods, buts other than peanuts 6/10/

55 6/10/

56 Step 1. Look up in the Alphabetic Index Admission (for) - see also Encounter (for) Encounter (with health service) (for) Z chemotherapy for neoplasm Z51.11 Step 2. Verify in the Tabular List Z51 Encounter for other aftercare Code also condition requiring care Excludes1: follow-up examination after treatment (Z08- Z09) Z51.0 Encounter for antineoplastic radiation therapy Z51.1 Encounter for antineoplastic chemotherapy and immunotherapy Excludes2: encounter for chemotherapy and immunotherapy for nonneoplastic condition - code to condition Z51.11 Encounter for antineoplastic chemotherapy Z51.12 Encounter for antineoplastic immunotherapy 6/10/

57 Step 1 Look in Alphabetic Index Neoplasm, neoplastic - see also Neoplasm table - Adrenal gland C /10/

58 History - family (of) - see also History, personal (of) - personal (of) - see also History, family (of) - - malignant melanoma (skin) Z Verify in Tabular List Z85.82 Personal history of malignant neoplasm of skin Z Personal history of malignant melanoma of skin Conditions classifiable to C43 Z Personal history of Merkel cell carcinoma Conditions classifiable to C4a Z Personal history of other malignant neoplasm of skin Conditions classifiable to C44 6/10/