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CPC Training > 21. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) > Flashcards

21. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) Flashcards

1
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    a. Use of Z codes in any healthcare setting
A

a. Use of Z codes in any healthcare setting
Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.

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2
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    b. Z Codes indicate a reason for an encounter
A

b. Z Codes indicate a reason for an encounter
Z codes are not procedure codes. A corresponding procedure code must accompany a Z code to describe any procedure performed.

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3
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    1) Contact/Exposure
A

c. Categories of Z Codes
1) Contact/Exposure
Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic.
Category Z77, Other contact with and (suspected) exposures hazardous to health, indicates contact with and suspected exposures hazardous to health.
Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk.

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4
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    2) Inoculations and vaccinations
A

2) Inoculations and vaccinations
Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.

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5
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    3) Status
A

3) Status
Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from ahistory code. The history code indicates that the patient no longer has the condition.
A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient.
For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, Chronic respiratory failure, followed by code Z99.11, Dependence on respirator [ventilator] status.

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6
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    3) Status
    Status Z codes:
A 
Z14 Genetic carrier
Z15 Genetic susceptibility to disease
Z16 Resistance to antimicrobial drugs
Z17 Estrogen receptor status
Z18 Retained foreign body fragments
Z19 Hormone sensitivity malignancy status
Z21 Asymptomatic HIV infection status
Z22 Carrier of infectious disease
Z28.3 Underimmunization status
Z33.1 Pregnant state, incidental
Z66 Do not resuscitate
Z67 Blood type
Z74.01 Bed confinement status
Z76.82 Awaiting organ transplant status
Z78 Other specified health status
Z79 Long-term (current) drug therapy
Z88 Allergy status to drugs, medicaments and biological substances
Z93 Artificial opening status
Z94 Transplanted organ and tissue status
Z95 Presence of cardiac and vascular implants and grafts
Z96 Presence of other functional implants
Z97 Presence of other devices
Z98 Other postprocedural states
Z99 Dependence on enabling machines and devices, not elsewhere classified
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7
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    4) History (of)
A

4) History (of)
There are two types of history Z codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.
Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.

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8
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    4) History (of)
    The history Z code categories are:
A

The history Z code categories are:
Z80 Family history of primary malignant neoplasm
Z81 Family history of mental and behavioral disorders
Z82 Family history of certain disabilities and chronic diseases (leading to disablement)
Z83 Family history of other specific disorders
Z84 Family history of other conditions
Z85 Personal history of malignant neoplasm
Z86 Personal history of certain other diseases
Z87 Personal history of other diseases and conditions
Z91.4- Personal history of psychological trauma, not elsewhere classified
Z91.5 Personal history of self-harm
Z91.8- Other specified personal risk factors, not elsewhere classified
Exception:
Z91.83, Wandering in diseases classified elsewhere
Z92 Personal history of medical treatment
Except: Z92.0, Personal history of contraception
Except: Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility

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9
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    5) Screening
A

5) Screening
Screening is the 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).
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. 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.
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.

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10
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    5) Screening
    The screening Z codes/categories:
A

The screening Z codes/categories:
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
Except: Z13.9, Encounter for screening, unspecified
Z36 Encounter for antenatal screening for mother

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11
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    6) Observation
A

6) Observation
There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.
The observation codes are to be used as principal diagnosis only. The only exception to this is when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery. Then a code from category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in addition to the observation code, but only if they are unrelated to the suspected condition being observed.
The observation Z code categories:
Z03 Encounter for medical observation for suspected diseases and conditions ruled out
Z04 Encounter for examination and observation for other reasons
Except: Z04.9, Encounter for examination and observation for unspecified reason
Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out

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12
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    7) Aftercare
A

7) Aftercare
Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule are codes Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be 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.

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13
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    7) Aftercare
    The aftercare Z category/codes:
A

The aftercare Z category/codes:
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 and medical ca

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14
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    8) Follow-up
A

8) Follow-up
The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes, or injury codes with a 7th character for subsequent encounter, that explain ongoing care of a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.
A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.
The follow-up Z code categories:
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

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15
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    9) Donor
A

9) Donor
Codes in category Z52, Donors of organs and tissues, are 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. They are not used to identify cadaveric donations.

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16
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    10) Counseling
A

10) Counseling
Counseling Z codes are 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. They are not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.
The counseling Z codes/categories:
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
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

17
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    11) Encounters for Obstetrical and Reproductive Services
A

11) Encounters for Obstetrical and Reproductive Services
See Section I.C.15. Pregnancy, Childbirth, and the Puerperium, for further instruction on the use of these codes.
Z codes for pregnancy are for use in those circumstances when none of the problems or complications included in the codes from the Obstetrics chapter exist (a routine prenatal visit or postpartum care). Codes in category Z34, Encounter for supervision of normal pregnancy, are always first-listed and are not to be used with any other code from the OB chapter.
Codes in category Z3A, Weeks of gestation, may be assigned to provide additional information about the pregnancy. Category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08), elective termination of pregnancy (code Z33.32), nor for postpartum conditions, as category Z3A is not applicable to these conditions. The date of the admission should be used to determine weeks of gestation for inpatient admissions that encompass more than one gestational week.
The outcome of delivery, category Z37, should be included on all maternal delivery records. It is always a secondary code. Codes in category Z37 should not be 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.

18
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    11) Encounters for Obstetrical and Reproductive Services
    Z codes/categories for obstetrical and reproductive services:
A

Z codes/categories for obstetrical and reproductive services:
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
Z3A Weeks of gestation
Z37 Outcome of delivery
Z39 Encounter for maternal postpartum care and examination
Z76.81 Expectant mother prebirth pediatrician visit

19
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    12) Newborns and Infants
A

12) Newborns and Infants
See Section I.C.16. Newborn (Perinatal) Guidelines, for further instruction on the use of these codes.
Newborn Z codes/categories:
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

20
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    13) Routine and administrative examinations
A

13) Routine and administrative examinations
The Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be 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. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the 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. Code assignment depends on the information that is known at the time the 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 a code for “with abnormal findings,” additional code(s) should be assigned to identify the specific abnormal finding(s).
Pre-operative examination and 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.

21
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    13) Routine and administrative examinations
    The Z codes/categories for routine and administrative examinations:
A

The Z codes/categories for routine and administrative examinations:
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
Except: Z02.9, Encounter for administrative examinations, unspecified
Z32.0- Encounter for pregnancy test

22
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    14) Miscellaneous Z codes
A

14) Miscellaneous Z codes
The miscellaneous Z codes capture a number of other health care encounters that do not fall into one of the other categories. Certain of these codes identify the reason for the encounter; others are for use as additional codes that provide useful information on circumstances that may affect a patient’s care and treatment.

23
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    14) Miscellaneous Z codes
    Miscellaneous Z codes/categories:
A

Miscellaneous Z codes/categories:
Z28 Immunization not carried out
Except: Z28.3, Underimmunization status
Z29 Encounter for other prophylactic measures
Z40 Encounter for prophylactic surgery
Z41 Encounter for procedures for purposes other than remedying health state
Except: Z41.9, Encounter for procedure for purposes other than remedying health state, unspecified
Z53 Persons encountering health services for specific procedures and treatment, not carried out
Z55 Problems related to education and literacy
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
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
Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem
Z73 Problems related to life management difficulty
Z74 Problems related to care provider dependency
Except: Z74.01, Bed confinement status
Z75 Problems related to medical facilities and other health care
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]
Z91.1- Patient’s noncompliance with medical treatment and regimen
Z91.83 Wandering in diseases classified elsewhere
Z91.89 Other specified personal risk factors, not elsewhere classified

24
Q
  1. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
    c. Categories of Z Codes
    16) Z Codes That May Only be Principal/First-Listed Diagnosis
A

16) Z Codes That May Only be Principal/First-Listed Diagnosis
The following Z codes/categories may only be reported 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:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
Except: Z00.6
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
Z04 Encounter for examination and observation for other reasons
Z33.2 Encounter for elective termination of pregnancy
Z31.81 Encounter for male factor infertility in female patient
Z31.83 Encounter for assisted reproductive fertility procedure cycle
Z31.84 Encounter for fertility preservation procedure
Z34 Encounter for supervision of normal pregnancy
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

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