•
(Notes) Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
(b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.
•
(Notes) Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.
•
(Excludes Type 1) examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)
•
(Excludes Type 1) encounter for examination for administrative purposes (Z02.-)
•
(Excludes Type 2) encounter for pre-procedural examinations (Z01.81-)
special screening examinations (Z11-Z13)
•
(Inclusion term) Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations
•
(Excludes Type 1) encounter for examination of sign or symptom- code to sign or symptom
general health check-up of infant or child (Z00.12.-)
•
(Inclusion term) Encounter for adult health check-up NOS
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Health check for child under 29 days old
•
(Use additional code) code to identify any abnormal findings
•
(Excludes Type 1) health check for child over 28 days old (Z00.12-)
•
(Inclusion term) Health check for newborn under 8 days old
•
(Inclusion term) Health check for newborn 8 to 28 days old
Newborn weight check
•
(Inclusion term) Health check (routine) for child over 28 days old
Immunizations appropriate for age
Routine developmental screening of infant or child
Routine vision and hearing testing
•
(Excludes Type 1) health check for child under 29 days old (Z00.11-)
health supervision of foundling or other healthy infant or child (Z76.1-Z76.2)
newborn health examination (Z00.11-)
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for routine child health examination NOS
•
(Inclusion term) Encounter for puberty development state
•
(Inclusion term) Examination of participant or control in clinical research program
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for health examination in population surveys
•
(Includes) routine examination of specific system
•
(Notes) Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed
•
(Excludes Type 1) encounter for examination for administrative purposes (Z02.-)
encounter for examination for suspected conditions, proven not to exist (Z03.-)
encounter for laboratory and radiologic examinations as a component of general medical examinations (Z00.0-)
encounter for laboratory, radiologic and imaging examinations for sign(s) and symptom(s) - code to the sign(s) or symptom(s)
•
(Excludes Type 2) screening examinations (Z11-Z13)
•
(Excludes Type 1) examination for driving license (Z02.4)
•
(Inclusion term) Encounter for examination of eyes and vision NOS
•
(Use additional code) code to identify abnormal findings
•
(Excludes Type 1) examination for examination of eyes and vision with abnormal findings (Z01.01)
examination for examination of eyes and vision without abnormal findings (Z01.00)
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for examination of ears and hearing NOS
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for dental examination and cleaning NOS
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for examination of blood pressure NOS
•
(Use additional code) code to identify abnormal findings
•
(Excludes Type 2) pregnancy examination or test (Z32.0-)
routine examination for contraceptive maintenance (Z30.4-)
•
(Inclusion term) Encounter for general gynecological examination with or without cervical smear
Encounter for gynecological examination (general) (routine) NOS
Encounter for pelvic examination (annual) (periodic)
•
(Use additional code) code:
for screening for human papillomavirus, if applicable, (Z11.51)
for screening vaginal pap smear, if applicable (Z12.72)
to identify acquired absence of uterus, if applicable (Z90.71-)
•
(Excludes Type 1) gynecologic examination status-post hysterectomy for malignant condition (Z08)
screening cervical pap smear not a part of a routine gynecological examination (Z12.4)
•
(Use additional code) code to identify abnormal findings
•
(Inclusion term) Encounter for preoperative examinations
Encounter for radiological and imaging examinations as part of preprocedural examination
•
(Inclusion term) Blood and urine tests prior to treatment or procedure
•
(Inclusion term) Encounter for preprocedural examination NOS
Encounter for examinations prior to antineoplastic chemotherapy
•
(Excludes Type 1) encounter for antibody response examination (Z01.84)
•
(Inclusion term) Encounter for Rh typing
•
(Inclusion term) Encounter for immunity status testing
•
(Excludes Type 1) encounter for allergy testing (Z01.82)
•
(Inclusion term) Encounter for examination for admission to preschool (education)
Encounter for examination for re-admission to school following illness or medical treatment
•
(Excludes Type 1) examination for admission to prison (Z02.89)
•
(Excludes Type 1) blood-alcohol and blood-drug test (Z02.83)
•
(Excludes Type 1) encounter for general medical examination (Z00-Z01, Z02.0-Z02.6, Z02.8-Z02.9)
•
(Inclusion term) Encounter for issue of medical certificate of incapacity
Encounter for issue of medical certificate of invalidity
•
(Use additional code) code for findings of alcohol or drugs in blood (R78.-)
•
(Inclusion term) Encounter for examination for admission to prison
Encounter for examination for admission to summer camp
Encounter for immigration examination
Encounter for naturalization examination
Encounter for premarital examination
•
(Excludes Type 1) health supervision of foundling or other healthy infant or child (Z76.1-Z76.2)
•
(Inclusion term) This category is to be used 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. This category is also for use for administrative and legal observation status.
•
(Excludes Type 1) contact with and (suspected) exposures hazardous to health (Z77.-)
encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out (Z05.-)
person with feared complaint in whom no diagnosis is made (Z71.1)
signs or symptoms under study- code to signs or symptoms
•
(Inclusion term) Encounter for observation for suspected adverse effect from drug
Encounter for observation for suspected poisoning
•
(Inclusion term) Encounter for suspected maternal and fetal conditions not found
•
(Excludes Type 1) known or suspected fetal anomalies affecting management of mother, not ruled out (O26.-, O35.-, O36.-, O40.-, O41.-)
•
(Inclusion term) Encounter for suspected oligohydramnios ruled out
Encounter for suspected polyhydramnios ruled out
•
(Includes) encounter for examination for medicolegal reasons
This category is to be used 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. This category is also for use for administrative and legal observation status.
•
(Excludes Type 1) encounter for examination and observation following work accident (Z04.2)
•
(Inclusion term) Encounter for examination and observation of victim following alleged rape
Encounter for examination and observation of victim following alleged sexual abuse
•
(Inclusion term) Suspected adult rape, ruled out
Suspected adult sexual abuse, ruled out
•
(Inclusion term) Suspected child rape, ruled out
Suspected child sexual abuse, ruled out
•
(Inclusion term) Suspected adult physical abuse, ruled out
•
(Excludes Type 1) confirmed case of adult physical abuse (T74.-)
encounter for examination and observation following alleged adult sexual abuse (Z04.41)
suspected case of adult physical abuse, not ruled out (T76.-)
•
(Inclusion term) Suspected child physical abuse, ruled out
•
(Excludes Type 1) confirmed case of child physical abuse (T74.-)
encounter for examination and observation following alleged child sexual abuse (Z04.42)
suspected case of child physical abuse, not ruled out (T76.-)
•
(Inclusion term) Encounter for examination and observation for request for expert evidence
•
(Inclusion term) Encounter for observation NOS
•
(Inclusion term) This category is to be used for newborns, within the neonatal period (the first 28 days of life), who are suspected of having an abnormal condition, but without signs or symptoms, and which, after examination and observation, is ruled out.
•
(Inclusion term) Medical surveillance following completed treatment
•
(Use additional code) code to identify any acquired absence of organs (Z90.-)
•
(Use additional code) code to identify the personal history of malignant neoplasm (Z85.-)
•
(Excludes Type 1) aftercare following medical care (Z43-Z49, Z51)
•
(Inclusion term) Medical surveillance following completed treatment
•
(Use additional code) code to identify any applicable history of disease code (Z86.-. Z87.-)
•
(Excludes Type 1) aftercare following medical care (Z43-Z49, Z51)
surveillance of contraception (Z30.4-)
surveillance of prosthetic and other medical devices (Z44-Z46)
•
(Inclusion term) Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.
•
(Excludes Type 1) encounter for diagnostic examination-code to sign or symptom
•
(Inclusion term) Encounter for screening for active tuberculosis disease
•
(Excludes Type 2) encounter for screening for human immunodeficiency virus [HIV] (Z11.4)
encounter for screening for human papillomavirus (Z11.51)
•
(Excludes Type 2) encounter for screening for viral intestinal disease (Z11.0)
•
(Excludes Type 2) encounter for screening for protozoal intestinal disease (Z11.0)
•
(Inclusion term) Encounter for screening for chlamydia
Encounter for screening for rickettsial
Encounter for screening for spirochetal
Encounter for screening for mycoses
•
(Inclusion term) Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.
•
(Use additional code) code to identify any family history of malignant neoplasm (Z80.-)
•
(Excludes Type 1) encounter for diagnostic examination-code to sign or symptom
•
(Inclusion term) Encounter for screening colonoscopy NOS
•
(Excludes Type 1) inconclusive mammogram (R92.2)
•
(Inclusion term) Encounter for screening pap smear for malignant neoplasm of cervix
•
(Excludes Type 1) when screening is part of general gynecological examination (Z01.4-)
•
(Excludes Type 2) encounter for screening for human papillomavirus (Z11.51)
•
(Inclusion term) Vaginal pap smear status-post hysterectomy for non-malignant condition
•
(Use additional code) code to identify acquired absence of uterus (Z90.71-)
•
(Excludes Type 1) vaginal pap smear status-post hysterectomy for malignant conditions (Z08)
•
(Inclusion term) Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.
•
(Excludes Type 1) encounter for diagnostic examination-code to sign or symptom
•
(Inclusion term) Encounter for screening for cholesterol level
Encounter for screening for hypercholesterolemia
Encounter for screening for hyperlipidemia
•
(Excludes Type 1) encounter for screening for diabetes mellitus (Z13.1)
•
(Inclusion term) Encounter for screening for depression, adult
Encounter for screening for depression for child or adolescent
•
(Inclusion term) Encounter for screening for perinatal depression
•
(Inclusion term) Encounter for screening for alcoholism
Encounter for screening for intellectual disabilities
•
(Inclusion term) Encounter for development testing of infant or child
Encounter for screening for developmental handicaps in early childhood
•
(Excludes Type 2) encounter for routine child health examination (Z00.12-)
•
(Inclusion term) Encounter for screening for developmental handicaps in early childhood
•
(Excludes Type 2) encounter for general hearing examination (Z01.1-)
encounter for general vision examination (Z01.0-)
•
(Excludes Type 1) genetic testing for procreative management (Z31.4-)
•
(Excludes Type 2) screening for malignant neoplasms (Z12.-)
•
(Excludes Type 1) encounter for screening for intestinal infectious disease (Z11.0)
•
(Excludes Type 1) encounter for screening for respiratory tuberculosis (Z11.1)
•
(Excludes Type 1) those exposed to contaminants without suspected disorders (Z57.-, Z77.-)
•
(Inclusion term) Encounter for screening for genitourinary disorders
•
(Excludes Type 1) carrier of infectious disease (Z22.-)
diagnosed current infectious or parasitic disease -see Alphabetic Index
•
(Excludes Type 2) personal history of infectious and parasitic diseases (Z86.1-)
•
(Excludes Type 1) asymptomatic human immunodeficiency virus [HIV]
HIV infection status (Z21)
•
(Inclusion term) HIV positive NOS
•
(Code first) Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium, if applicable (O98.7-)
•
(Excludes Type 1) acquired immunodeficiency syndrome (B20)
contact with human immunodeficiency virus [HIV] (Z20.6)
exposure to human immunodeficiency virus [HIV] (Z20.6)
human immunodeficiency virus [HIV] disease (B20)
inconclusive laboratory evidence of human immunodeficiency virus [HIV] (R75)
•
(Includes) colonization status
suspected carrier
•
(Excludes Type 2) carrier of viral hepatitis (B18.-)
•
(Inclusion term) MSSA colonization
•
(Inclusion term) MRSA colonization
•
(Excludes Type 1) Carrier of streptococcus group B (GBS) complicating pregnancy, childbirth and the puerperium (O99.82-)
•
(Inclusion term) Latent tuberculosis infection (LTBI)
•
(Excludes Type 1) nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis (R76.12)
nonspecific reaction to tuberculin skin test without active tuberculosis (R76.11)
•
(Code first) any routine childhood examination
•
(Notes) procedure codes are required to identify the types of immunizations given
•
(Includes) vaccination not carried out
•
(Inclusion term) Immunization not carried out because of religious belief
•
(Inclusion term) Delinquent immunization status
Lapsed immunization schedule status
•
(Inclusion term) Immunization not carried out because of guardian refusal
Immunization not carried out because of parent refusal
•
(Excludes Type 1) immunization not carried out because of caregiver refusal because of religious belief (Z28.1)
•
(Inclusion term) Delay in delivery of vaccine
Lack of availability of vaccine
Manufacturer delay of vaccine
•
(Excludes Type 1) desensitization to allergens (Z51.6)
prophylactic surgery (Z40.-)
•
(Inclusion term) Encounter for administration of immunoglobulin
•
(Excludes Type 1) encounter for surveillance of contraceptives (Z30.4-)
•
(Inclusion term) Encounter for postcoital contraception
•
(Excludes Type 1) encounter for insertion of intrauterine contraceptive device (Z30.430, Z30.432)
•
(Inclusion term) Encounter for initial prescription of barrier contraception
Encounter for initial prescription of diaphragm
•
(Inclusion term) Encounter for family planning advice NOS
•
(Inclusion term) Encounter for repeat prescription for contraceptive pill
•
(Inclusion term) Encounter for replacement of intrauterine contraceptive device
•
(Inclusion term) Encounter for checking, reinsertion or removal of implantable subdermal contraceptive
•
(Inclusion term) Encounter for surveillance of barrier contraception
Encounter for surveillance of diaphragm
•
(Inclusion term) Encounter for postvasectomy sperm count
Encounter for routine examination for contraceptive maintenance
•
(Excludes Type 1) sperm count following sterilization reversal (Z31.42)
sperm count for fertility testing (Z31.41)
•
(Excludes Type 1) complications associated with artificial fertilization (N98.-)
female infertility (N97.-)
male infertility (N46.-)
•
(Excludes Type 1) postvasectomy sperm count (Z30.8)
•
(Inclusion term) Encounter for fallopian tube patency testing
Encounter for sperm count for fertility testing
•
(Inclusion term) Sperm count following sterilization reversal
•
(Use additional code) code for recurrent pregnancy loss, if applicable (N96, O26.2-)
•
(Excludes Type 1) nonprocreative genetic testing (Z13.7-)
•
(Excludes Type 1) nonprocreative genetic testing (Z13.7-)
•
(Inclusion term) Encounter for fertility preservation counseling prior to cancer therapy
Encounter for fertility preservation counseling prior to surgical removal of gonads
•
(Excludes Type 1) pregnant state, gestational carrier (Z33.3)
•
(Inclusion term) Patient undergoing in vitro fertilization cycle
•
(Use additional code) code to identify the type of infertility
•
(Excludes Type 1) pre-cycle diagnosis and testing - code to reason for encounter
•
(Inclusion term) Encounter for fertility preservation procedure prior to cancer therapy
Encounter for fertility preservation procedure prior to surgical removal of gonads
•
(Inclusion term) Encounter for pregnancy test NOS
•
(Inclusion term) Encounter for prenatal or postpartum childcare instruction
•
(Inclusion term) Pregnant state NOS
•
(Excludes Type 1) complications of pregnancy (O00-O9A)
pregnant state, gestational carrier (Z33.3)
•
(Excludes Type 1) early fetal death with retention of dead fetus (O02.1)
late fetal death (O36.4)
spontaneous abortion (O03)
•
(Excludes Type 1) encounter for procreative management and counseling for gestational carrier (Z31.7)
•
(Excludes Type 1) any complication of pregnancy (O00-O9A)
encounter for pregnancy test (Z32.0-)
encounter for supervision of high risk pregnancy (O09.-)
•
(Includes) Encounter for placental sample (taken vaginally)
Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease.
•
(Excludes Type 1) diagnostic examination- code to sign or symptom
encounter for suspected maternal and fetal conditions ruled out (Z03.7-)
suspected fetal condition affecting management of pregnancy - code to condition in Chapter 15
•
(Excludes Type 2) abnormal findings on antenatal screening of mother (O28.-)
genetic counseling and testing (Z31.43-, Z31.5)
routine prenatal care (Z34)
•
(Inclusion term) Encounter for antenatal screening for elevated maternal serum alphafetoprotein level
•
(Inclusion term) Non-visualized anatomy on a previous scan
•
(Inclusion term) Screening for a suspected anomaly
•
(Inclusion term) Intrauterine growth restriction (IUGR)/small-for-dates
•
(Inclusion term) Screening for risk of pre-term labor
•
(Inclusion term) Screening for large-for-dates
•
(Notes) Codes from category Z3A are for use, only on the maternal record, to indicate the weeks of gestation of the pregnancy, if known.
•
(Code first) complications of pregnancy, childbirth and the puerperium (O09-O9A)
•
(Inclusion term) This category is intended for use as an additional code to identify the outcome of delivery on the mother's record. It is not for use on the newborn record.
•
(Excludes Type 1) stillbirth (P95)
•
(Inclusion term) Multiple birth NOS
Single birth NOS
•
(Inclusion term) This category is for use as the principal code on the initial record of a newborn baby. It is to be used for the initial birth record only. It is not to be used on the mother's record.
•
(Inclusion term) Single liveborn infant, born in birthing center or other health care facility
•
(Inclusion term) Single liveborn infant NOS
•
(Inclusion term) Care and observation in uncomplicated cases when the delivery occurs outside a healthcare facility
•
(Excludes Type 1) care for postpartum complication- see Alphabetic index
•
(Inclusion term) Encounter for supervision of lactation
•
(Excludes Type 1) disorders of lactation (O92.-)
•
(Inclusion term) Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state
•
(Excludes Type 2) follow-up examination for medical surveillance after treatment (Z08-Z09)
•
(Excludes Type 1) organ donations (Z52.-)
therapeutic organ removal-code to condition
•
(Inclusion term) Admission for prophylactic organ removal
•
(Use additional code) code to identify risk factor
•
(Inclusion term) Encounter for prophylactic removal of ovary(s) and fallopian tube(s)
•
(Inclusion term) Encounter for cosmetic breast implant
Encounter for cosmetic procedure
•
(Excludes Type 1) encounter for plastic and reconstructive surgery following medical procedure or healed injury (Z42.-)
encounter for post-mastectomy breast implantation (Z42.1)
•
(Excludes Type 1) encounter for cosmetic plastic surgery (Z41.1)
encounter for plastic surgery for treatment of current injury - code to relevent injury
•
(Excludes Type 1) deformity and disproportion of reconstructed breast (N65.1-)
•
(Includes) closure of artificial openings
passage of sounds or bougies through artificial openings
reforming artificial openings
removal of catheter from artificial openings
toilet or cleansing of artificial openings
•
(Excludes Type 1) complications of external stoma (J95.0-, K94.-, N99.5-)
•
(Excludes Type 2) fitting and adjustment of prosthetic and other devices (Z44-Z46)
•
(Excludes Type 2) artificial opening status only, without need for care (Z93.-)
•
(Inclusion term) Encounter for attention to nephrostomy
Encounter for attention to ureterostomy
Encounter for attention to urethrostomy
•
(Includes) removal or replacement of external prosthetic device
•
(Excludes Type 1) malfunction or other complications of device - see Alphabetical Index
presence of prosthetic device (Z97.-)
•
(Excludes Type 1) mechanical complication of ocular prosthesis (T85.3)
•
(Excludes Type 1) complications of breast implant (T85.4-)
encounter for adjustment or removal of breast implant (Z45.81-)
encounter for initial breast implant insertion for cosmetic breast augmentation (Z41.1)
encounter for breast reconstruction following mastectomy (Z42.1)
•
(Includes) removal or replacement of implanted device
•
(Excludes Type 1) malfunction or other complications of device - see Alphabetical Index
•
(Excludes Type 2) encounter for fitting and adjustment of non-implanted device (Z46.-)
•
(Inclusion term) Encounter for adjustment and management of cardiac resynchronization therapy pacemaker (CRT-P)
•
(Excludes Type 1) encounter for adjustment and management of automatic implantable cardiac defibrillator with synchronous cardiac pacemaker (Z45.02)
•
(Inclusion term) Encounter for replacing cardiac pacemaker pulse generator [battery]
•
(Excludes Type 1) presence of other part of cardiac pacemaker (Z95.0)
•
(Excludes Type 2) presence of prosthetic and other devices (Z95.1-Z95.5, Z95.811-Z97)
•
(Inclusion term) Encounter for adjustment and management of automatic implantable cardiac defibrillator with synchronous cardiac pacemaker
Encounter for adjustment and management of cardiac resynchronization therapy defibrillator (CRT-D)
•
(Inclusion term) Encounter for adjustment and management of vascular catheters
•
(Excludes Type 1) encounter for adjustment and management of renal dialysis catheter (Z49.01)
•
(Excludes Type 1) Encounter for fitting and adjustment of hearing aide (Z46.1)
•
(Inclusion term) Encounter for adjustment and management of cerebral ventricular (communicating) shunt
•
(Inclusion term) Encounter for adjustment and management of brain neurostimulator
Encounter for adjustment and management of gastric neurostimulator
Encounter for adjustment and management of peripheral nerve neurostimulator
Encounter for adjustment and management of sacral nerve neurostimulator
Encounter for adjustment and management of spinal cord neurostimulator
Encounter for adjustment and management of vagus nerve neurostimulator
•
(Inclusion term) Encounter for elective implant exchange (different material) (different size)
Encounter removal of tissue expander with or without synchronous insertion of permanent implant
•
(Excludes Type 1) complications of breast implant (T85.4-)
encounter for initial breast implant insertion for cosmetic breast augmentation (Z41.1)
encounter for breast reconstruction following mastectomy (Z42.1)
•
(Includes) removal or replacement of other device
•
(Excludes Type 1) malfunction or other complications of device - see Alphabetical Index
•
(Excludes Type 2) encounter for fitting and management of implanted devices (Z45.-)
issue of repeat prescription only (Z76.0)
presence of prosthetic and other devices (Z95-Z97)
•
(Excludes Type 1) encounter for adjustment and management of implanted hearing device (Z45.32-)
•
(Excludes Type 2) encounter for adjustment and management of implanted nervous system device (Z45.4-)
encounter for adjustment and management of implanted visual substitution device (Z45.31)
•
(Inclusion term) Encounter for fitting and adjustment of dentures
•
(Excludes Type 1) encounter for attention to artificial openings of digestive tract (Z43.1-Z43.4)
•
(Excludes Type 2) attention to artificial openings of urinary tract (Z43.5, Z43.6)
•
(Inclusion term) Encounter for insulin pump instruction and training
Encounter for insulin pump titration
•
(Inclusion term) Encounter for fitting and adjustment of wheelchair
•
(Excludes Type 1) aftercare for healing fracture-code to fracture with 7th character D
•
(Use additional code) code to identify the joint (Z96.6-)
•
(Excludes Type 1) encounter for adjustment of internal fixation device for fracture treatment- code to fracture with appropriate 7th character
encounter for removal of external fixation device- code to fracture with 7th character D
infection or inflammatory reaction to internal fixation device (T84.6-)
mechanical complication of internal fixation device (T84.1-)
•
(Inclusion term) Aftercare following explantation of joint prosthesis, staged procedure
Encounter for joint prosthesis insertion following prior explantation of joint prosthesis
•
(Excludes Type 1) acquired absence of shoulder joint following prior explantation of shoulder joint prosthesis (Z89.23-)
shoulder joint prosthesis explantation status (Z89.23-)
•
(Excludes Type 1) acquired absence of hip joint following prior explantation of hip joint prosthesis (Z89.62-)
hip joint prosthesis explantation status (Z89.62-)
•
(Excludes Type 1) acquired absence of knee joint following prior explantation of knee prosthesis (Z89.52-
knee joint prosthesis explantation status (Z89.52-)
•
(Use additional code) code to identify the limb amputated (Z89.-)
•
(Excludes Type 1) encounter for follow-up examination after completed treatment (Z08-Z09)
encounter for aftercare following injury - code to Injury, by site, with appropriate 7th character for subsequent encounter
•
(Excludes Type 2) encounter for attention to artificial openings (Z43.-)
encounter for fitting and adjustment of prosthetic and other devices (Z44-Z46)
•
(Excludes Type 1) encounter for planned postprocedural wound closure (Z48.1)
•
(Inclusion term) Encounter for change or removal of wound dressing NOS
•
(Inclusion term) Encounter for removal of staples
•
(Excludes Type 1) encounter for attention to dressings and sutures (Z48.0-)
•
(Use additional code) code to identify the neoplasm
•
(Inclusion term) These codes identify the body system requiring aftercare. They are for use in conjunction with other aftercare codes to fully explain the aftercare encounter. The condition treated should also be coded if still present.
•
(Excludes Type 1) aftercare for injury- code the injury with 7th character D
aftercare following surgery for neoplasm (Z48.3)
•
(Excludes Type 2) aftercare following organ transplant (Z48.2-)
orthopedic aftercare (Z47.-)
•
(Excludes Type 2) encounter for surgical aftercare following surgery on the sense organs (Z48.810)
•
(Excludes Type 1) encounter for aftercare following sterilization reversal (Z31.42)
•
(Code Also) associated end stage renal disease (N18.6)
•
(Inclusion term) Encounter for dialysis instruction and training
•
(Inclusion term) Removal or replacement of renal dialysis catheter
Toilet or cleansing of renal dialysis catheter
•
(Inclusion term) Encounter for peritoneal equilibration test
•
(Code Also) condition requiring care
•
(Excludes Type 1) follow-up examination after treatment (Z08-Z09)
•
(Excludes Type 2) encounter for chemotherapy and immunotherapy for nonneoplastic condition - code to condition
•
(Excludes Type 1) holiday relief care (Z75.5)
•
(Code Also) any long-term (current) drug therapy (Z79.-)
•
(Excludes Type 1) encounter for blood-drug test for administrative or medicolegal reasons (Z02.83)
•
(Includes) autologous and other living donors
•
(Excludes Type 1) cadaveric donor - omit code
examination of potential donor (Z00.5)
•
(Inclusion term) Volunteer donor
•
(Inclusion term) Egg donor under age 35 NOS
•
(Inclusion term) Egg donor age 35 and over NOS
•
(Inclusion term) Donor NOS
•
(Excludes Type 1) disorders of psychological development (F80-F89)
•
(Inclusion term) Problems related to inadequate teaching
•
(Inclusion term) Academic problems NOS
•
(Excludes Type 2) occupational exposure to risk factors (Z57.-)
problems related to housing and economic circumstances (Z59.-)
•
(Inclusion term) Difficult conditions at work
•
(Inclusion term) Individual (civilian or military) currently deployed in theater or in support of military war, peacekeeping and humanitarian operations
•
(Inclusion term) Occupational problems NOS
•
(Excludes Type 2) exposure to environmental tobacco smoke (Z77.22)
•
(Inclusion term) Occupational exposure to solids, liquids, gases or vapors in agriculture
•
(Inclusion term) Occupational exposure to solids, liquids, gases or vapors in other industries
•
(Excludes Type 2) problems related to upbringing (Z62.-)
•
(Inclusion term) Lack of heating
Restriction of space
Technical defects in home preventing adequate care
Unsatisfactory surroundings
•
(Excludes Type 1) problems related to the natural and physical environment (Z77.1-)
•
(Inclusion term) Boarding-school resident
•
(Excludes Type 1) institutional upbringing (Z62.2)
•
(Inclusion term) Inadequate drinking water supply
•
(Excludes Type 1) effects of hunger (T73.0)
inappropriate diet or eating habits (Z72.4)
malnutrition (E40-E46)
•
(Inclusion term) Foreclosure on loan
Isolated dwelling
Problems with creditors
•
(Inclusion term) Empty nest syndrome
Phase of life problem
Problem with adjustment to retirement [pension]
•
(Inclusion term) Problem with migration
Problem with social transplantation
•
(Inclusion term) Exclusion and rejection on the basis of personal characteristics, such as unusual physical appearance, illness or behavior.
•
(Excludes Type 1) target of adverse discrimination such as for racial or religious reasons (Z60.5)
•
(Excludes Type 1) social exclusion and rejection (Z60.4)
•
(Includes) current and past negative life events in childhood
current and past problems of a child related to upbringing
•
(Excludes Type 2) maltreatment syndrome (T74.-)
problems related to housing and economic circumstances (Z59.-)
•
(Excludes Type 1) problems with boarding school (Z59.3)
•
(Inclusion term) Child in care of non-parental family member
Child in foster care
•
(Excludes Type 2) problem for parent due to child in welfare custody (Z63.5)
•
(Inclusion term) Child living in orphanage or group home
•
(Excludes Type 1) current child physical abuse (T74.12, T76.12)
current child sexual abuse (T74.22, T76.22)
•
(Excludes Type 1) current child psychological abuse (T74.32, T76.32)
•
(Excludes Type 1) current child neglect (T74.02, T76.02)
•
(Excludes Type 1) current child abuse NOS (T74.92, T76.92)
•
(Inclusion term) Parent-child problem NOS
•
(Excludes Type 2) maltreatment syndrome (T74.-, T76)
parent-child problems (Z62.-)
problems related to negative life events in childhood (Z62.-)
problems related to upbringing (Z62.-)
•
(Inclusion term) Relationship distress with spouse or intimate partner
•
(Excludes Type 1) counseling for spousal or partner abuse problems (Z69.1)
counseling related to sexual attitude, behavior, and orientation (Z70.-)
•
(Excludes Type 1) absence of family member due to disappearance and death (Z63.4)
absence of family member due to separation and divorce (Z63.5)
•
(Inclusion term) Individual or family affected by other family member being on military deployment
•
(Excludes Type 1) family disruption due to return of family member from military deployment (Z63.71)
•
(Inclusion term) Assumed death of family member
Bereavement
•
(Inclusion term) Marital estrangement
•
(Inclusion term) Individual or family affected by family member having returned from military deployment (current or past conflict)
•
(Inclusion term) Anxiety (normal) about sick person in family
Health problems within family
Ill or disturbed family member
Isolated family
•
(Inclusion term) Family discord NOS
Family estrangement NOS
High expressed emotional level within family
Inadequate family support NOS
Inadequate or distorted communication within family
•
(Inclusion term) Relationship disorder NOS
•
(Inclusion term) Discord with probation officer
Discord with social worker
•
(Inclusion term) Arrest
Child custody or support proceedings
Litigation
Prosecution
•
(Inclusion term) Victim of torture
•
(Excludes Type 1) target of perceived discrimination or persecution (Z60.5)
•
(Inclusion term) Religious or spiritual problem
•
(Includes) counseling for victims and perpetrators of abuse
•
(Inclusion term) Encounter for mental health services for victim of child abuse by parent
Encounter for mental health services for victim of child neglect by parent
Encounter for mental health services for victim of child psychological abuse by parent
Encounter for mental health services for victim of child sexual abuse by parent
•
(Inclusion term) Encounter for mental health services for perpetrator of parental child neglect
Encounter for mental health services for perpetrator of parental child psychological abuse
Encounter for mental health services for perpetrator of parental child sexual abuse
•
(Excludes Type 1) encounter for mental health services for non-parental child abuse (Z69.02-)
•
(Inclusion term) Encounter for mental health services for victim of non-parental child neglect
Encounter for mental health services for victim of non-parental child psychological abuse
Encounter for mental health services for victim of non-parental child sexual abuse
•
(Inclusion term) Encounter for mental health services for perpetrator of non-parental child neglect
Encounter for mental health services for perpetrator of non-parental child psychological abuse
Encounter for mental health services for perpetrator of non-parental child sexual abuse
•
(Inclusion term) Encounter for mental health services for victim of spouse or partner neglect
Encounter for mental health services for victim of spouse or partner psychological abuse
Encounter for mental health services for victim of spouse or partner violence, physical
•
(Inclusion term) Encounter for mental health services for perpetrator of spouse or partner neglect
Encounter for mental health services for perpetrator of spouse or partner psychological abuse
Encounter for mental health services for perpetrator of spouse or partner violence, physical
Encounter for mental health services for perpetrator of spouse or partner violence, sexual
•
(Inclusion term) Encounter for mental health services for victim of non-spousal adult abuse
Encounter for mental health services for victim of spouse or partner violence, sexual
Encounter for rape victim counseling
•
(Inclusion term) Encounter for mental health services for perpetrator of non-spousal adult abuse
•
(Includes) encounter for mental health services for sexual attitude, behavior and orientation
•
(Excludes Type 2) contraceptive or procreative counseling (Z30-Z31)
•
(Inclusion term) Patient concerned regarding impotence
Patient concerned regarding non-responsiveness
Patient concerned regarding promiscuity
Patient concerned regarding sexual orientation
•
(Inclusion term) Advice sought regarding sexual behavior and orientation of child
Advice sought regarding sexual behavior and orientation of partner
Advice sought regarding sexual behavior and orientation of spouse
•
(Inclusion term) Encounter for sex education
•
(Excludes Type 2) contraceptive or procreation counseling (Z30-Z31)
sex counseling (Z70.-)
•
(Inclusion term) Person encountering health services to seek advice or treatment for non-attending third party
•
(Excludes Type 2) anxiety (normal) about sick person in family (Z63.7)
expectant (adoptive) parent(s) pre-birth pediatrician visit (Z76.81)
•
(Inclusion term) Person encountering health services with feared condition which was not demonstrated
Person encountering health services in which problem was normal state
'Worried well'
•
(Excludes Type 1) medical observation for suspected diseases and conditions proven not to exist (Z03.-)
•
(Use additional code) code for any associated underlying medical condition
•
(Use additional code) code to identify body mass index (BMI), if known (Z68.-)
•
(Use additional code) code for alcohol abuse or dependence (F10.-)
•
(Inclusion term) Counseling for significant other, partner, or friend of alcoholic
•
(Use additional code) code for drug abuse or dependence (F11-F16, F18-F19)
•
(Inclusion term) Counseling for significant other, partner, or friend of drug abuser
•
(Use additional code) code for nicotine dependence (F17.-)
•
(Excludes Type 2) counseling for contraception (Z30.0-)
•
(Excludes Type 1) counseling for procreative genetics (Z31.5)
counseling for procreative management (Z31.6)
•
(Inclusion term) Encounter for health risk and safety counseling for (international) travel
•
(Code Also) , if applicable, encounter for immunization (Z23)
•
(Excludes Type 2) encounter for administrative examination (Z02.-)
encounter for other special examination without complaint, suspected or reported diagnosis (Z01.-)
•
(Inclusion term) Encounter for medical advice NOS
•
(Excludes Type 2) problems related to life-management difficulty (Z73.-)
problems related to socioeconomic and psychosocial circumstances (Z55-Z65)
•
(Inclusion term) Tobacco use NOS
•
(Excludes Type 1) history of tobacco dependence (Z87.891)
nicotine dependence (F17.2-)
tobacco dependence (F17.2-)
tobacco use during pregnancy (O99.33-)
•
(Excludes Type 1) behavioral eating disorders of infancy or childhood (F98.2.-F98.3)
eating disorders (F50.-)
lack of adequate food (Z59.4)
malnutrition and other nutritional deficiencies (E40-E64)
•
(Inclusion term) Promiscuity
•
(Excludes Type 1) paraphilias (F65)
•
(Excludes Type 1) compulsive or pathological gambling (F63.0)
•
(Excludes Type 1) conduct disorders (F91.-)
•
(Inclusion term) Antisocial behavior (child) (adolescent) without manifest psychiatric disorder
Delinquency NOS
Group delinquency
Offenses in the context of gang membership
Stealing in company with others
Truancy from school
•
(Inclusion term) Adult antisocial behavior without manifest psychiatric disorder
•
(Inclusion term) Lack of adequate sleep
•
(Excludes Type 1) insomnia (G47.0-)
•
(Inclusion term) Bad sleep habits
Irregular sleep habits
Unhealthy sleep wake schedule
•
(Excludes Type 1) insomnia (F51.0-, G47.0-)
•
(Inclusion term) Self-damaging behavior
•
(Excludes Type 2) problems related to socioeconomic and psychosocial circumstances (Z55-Z65)
•
(Inclusion term) Physical and mental strain NOS
•
(Excludes Type 1) stress related to employment or unemployment (Z56.-)
•
(Excludes Type 1) care-provider dependency (Z74.-)
•
(Excludes Type 2) dependence on enabling machines or devices NEC (Z99.-)
•
(Inclusion term) Bedridden
•
(Inclusion term) Chairridden
Reduced mobility NOS
•
(Excludes Type 2) wheelchair dependence (Z99.3)
•
(Excludes Type 1) no other household member able to render care (Z74.2)
•
(Excludes Type 1) bed unavailable (Z75.1)
•
(Inclusion term) Encounter for issue of repeat prescription for appliance
Encounter for issue of repeat prescription for medicaments
Encounter for issue of repeat prescription for spectacles
•
(Excludes Type 2) issue of medical certificate (Z02.7)
repeat prescription for contraceptive (Z30.4-)
•
(Inclusion term) Encounter for medical or nursing care or supervision of healthy infant under circumstances such as adverse socioeconomic conditions at home
Encounter for medical or nursing care or supervision of healthy infant under circumstances such as awaiting foster or adoptive placement
Encounter for medical or nursing care or supervision of healthy infant under circumstances such as maternal illness
Encounter for medical or nursing care or supervision of healthy infant under circumstances such as number of children at home preventing or interfering with normal care
•
(Excludes Type 1) homelessness (Z59.0)
•
(Inclusion term) Person feigning illness (with obvious motivation)
•
(Excludes Type 1) factitious disorder (F68.1-, F68.A)
peregrinating patient (F68.1-)
•
(Inclusion term) Pre-adoption pediatrician visit for adoptive parent(s)
•
(Inclusion term) Patient waiting for organ availability
•
(Inclusion term) Persons encountering health services NOS
•
(Code Also) any follow-up examination (Z08-Z09)
•
(Includes) contact with and (suspected) exposures to potential hazards to health
•
(Excludes Type 2) contact with and (suspected) exposure to communicable diseases (Z20.-)
exposure to (parental) (environmental) tobacco smoke in the perinatal period (P96.81)
newborn affected by noxious substances transmitted via placenta or breast milk (P04.-)
occupational exposure to risk factors (Z57.-)
retained foreign body (Z18.-)
retained foreign body fully removed (Z87.821)
toxic effects of substances chiefly nonmedicinal as to source (T51-T65)
•
(Excludes Type 1) retained depleted uranium fragments (Z18.01)
•
(Inclusion term) Contact with and (suspected) exposure to chromium compounds
Contact with and (suspected) exposure to nickel dust
•
(Inclusion term) Aromatic dyes NOS
Polycyclic aromatic hydrocarbons
•
(Inclusion term) Dyes NOS
•
(Inclusion term) Contact with and (suspected) exposure to (harmful) algae bloom NOS
Contact with and (suspected) exposure to blue-green algae bloom
Contact with and (suspected) exposure to brown tide
Contact with and (suspected) exposure to cyanobacteria bloom
Contact with and (suspected) exposure to Florida red tide
Contact with and (suspected) exposure to pfiesteria piscicida
Contact with and (suspected) exposure to red tide
•
(Excludes Type 2) radiation exposure as the cause of a confirmed condition (W88-W90, X39.0-)
radiation sickness NOS (T66)
•
(Inclusion term) Exposure to second hand tobacco smoke (acute) (chronic)
Passive smoking (acute) (chronic)
•
(Excludes Type 1) nicotine dependence (F17.-)
tobacco use (Z72.0)
•
(Excludes Type 2) occupational exposure to environmental tobacco smoke (Z57.31)
•
(Excludes Type 2) asymptomatic human immunodeficiency virus [HIV] infection status (Z21)
postprocedural status (Z93-Z99)
sex reassignment status (Z87.890)
•
(Inclusion term) Menopausal state NOS
Postmenopausal status NOS
•
(Excludes Type 2) symptomatic menopausal state (N95.1)
•
(Excludes Type 1) physical restraint due to a procedure - omit code
•
(Includes) long term (current) drug use for prophylactic purposes
•
(Code Also) any therapeutic drug level monitoring (Z51.81)
•
(Excludes Type 2) drug abuse and dependence (F11-F19)
drug use complicating pregnancy, childbirth, and the puerperium (O99.32-)
long term (current) use of oral antidiabetic drugs (Z79.84)
long term (current) use of oral hypoglycemic drugs (Z79.84)
•
(Excludes Type 2) long term (current) use of aspirin (Z79.82)
•
(Excludes Type 2) long term (current) use of aspirin (Z79.82)
•
(Inclusion term) Long term (current) use of birth control pill or patch
•
(Code first) , if applicable:
malignant neoplasm of breast (C50.-)
malignant neoplasm of prostate (C61)
•
(Use additional code) code, if applicable, to identify:
estrogen receptor positive status (Z17.0)
family history of breast cancer (Z80.3)
genetic susceptibility to malignant neoplasm (cancer) (Z15.0-)
personal history of breast cancer (Z85.3)
personal history of prostate cancer (Z85.46)
postmenopausal status (Z78.0)
•
(Excludes Type 1) hormone replacement therapy (Z79.890)
•
(Inclusion term) Long term (current) use of raloxifene (Evista)
Long term (current) use of tamoxifen (Nolvadex)
Long term (current) use of toremifene (Fareston)
•
(Inclusion term) Long term (current) use of anastrozole (Arimidex)
Long term (current) use of exemestane (Aromasin)
Long term (current) use of letrozole (Femara)
•
(Inclusion term) Long term (current) use of estrogen receptor downregulators
Long term (current) use of fulvestrant (Faslodex)
Long term (current) use of gonadotropin-releasing hormone (GnRH) agonist
Long term (current) use of goserelin acetate (Zoladex)
Long term (current) use of leuprolide acetate (leuprorelin) (Lupron)
Long term (current) use of megestrol acetate (Megace)
•
(Inclusion term) Long term (current) use of oral antidiabetic drugs
•
(Excludes Type 2) long term (current) use of insulin (Z79.4)
•
(Inclusion term) Long term (current) use of methadone for pain management
•
(Excludes Type 1) methodone use NOS (F11.9-)
use of methodone for treatment of heroin addiction (F11.2-)
•
(Inclusion term) Conditions classifiable to C15-C26
•
(Inclusion term) Conditions classifiable to C33-C34
•
(Inclusion term) Conditions classifiable to C30-C32, C37-C39
•
(Inclusion term) Conditions classifiable to C50.-
•
(Inclusion term) Conditions classifiable to C51-C63
•
(Inclusion term) Conditions classifiable to C64-C68
•
(Inclusion term) Conditions classifiable to C91-C95
•
(Inclusion term) Conditions classifiable to C81-C90, C96.-
•
(Inclusion term) Conditions classifiable to C00-C14, C40-C49, C69-C79
•
(Inclusion term) Conditions classifiable to C80.1
•
(Inclusion term) Conditions classifiable to F70-F79
•
(Inclusion term) Conditions classifiable to F10.-
•
(Inclusion term) Conditions classifiable to F17.-
•
(Inclusion term) Conditions classifiable to F11-F16, F18-F19
•
(Inclusion term) Conditions classifiable to F55
•
(Inclusion term) Conditions classifiable elsewhere in F01-F99
•
(Inclusion term) Conditions classifiable to G00-G99
•
(Inclusion term) Conditions classifiable to H54.-
•
(Inclusion term) Conditions classifiable to H90-H91
•
(Inclusion term) Conditions classifiable to I60-I64
•
(Inclusion term) Conditions classifiable to I00-I52, I65-I99
•
(Inclusion term) Conditions classifiable to J40-J47
•
(Excludes Type 2) family history of other diseases of the respiratory system (Z83.6)
•
(Inclusion term) Conditions classifiable to M00-M99
•
(Inclusion term) Conditions classifiable to Q00-Q99
•
(Excludes Type 2) contact with and (suspected) exposure to communicable disease in the family (Z20.-)
•
(Inclusion term) Conditions classifiable to B20
•
(Inclusion term) Conditions classifiable to A00-B19, B25-B94, B99
•
(Inclusion term) Conditions classifiable to D50-D89
•
(Inclusion term) Conditions classifiable to E08-E13
•
(Inclusion term) Conditions classifiable to E00-E07, E15-E88
•
(Inclusion term) Family history of elevated Lp(a)
•
(Inclusion term) Family history of familial combined hyperlipidemia
•
(Inclusion term) Conditions classifiable to H00-H53, H55-H59
•
(Excludes Type 2) family history of blindness and visual loss (Z82.1)
•
(Inclusion term) Conditions classifiable to H60-H83, H92-H95
•
(Excludes Type 2) family history of deafness and hearing loss (Z82.2)
•
(Inclusion term) Conditions classifiable to J00-J39, J60-J99
•
(Excludes Type 2) family history of asthma and other chronic lower respiratory diseases (Z82.5)
•
(Inclusion term) Conditions classifiable to K00-K93
•
(Excludes Type 2) family history of malignant neoplasm of digestive organs (Z80.0)
•
(Inclusion term) Conditions classifiable to L00-L99
•
(Inclusion term) Conditions classifiable to N00-N29
•
(Inclusion term) Conditions classifiable to N30-N99
•
(Inclusion term) Family history of SIDS
•
(Code first) any follow-up examination after treatment of malignant neoplasm (Z08)
•
(Use additional code) code to identify:
alcohol use and dependence (F10.-)
exposure to environmental tobacco smoke (Z77.22)
history of tobacco dependence (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
•
(Excludes Type 2) personal history of benign neoplasm (Z86.01-)
personal history of carcinoma-in-situ (Z86.00-)
•
(Inclusion term) Conditions classifiable to C15
•
(Inclusion term) Conditions classifiable to C7A.092
•
(Inclusion term) Conditions classifiable to C16
•
(Inclusion term) Conditions classifiable to C7A.022-C7A.025, C7A.029
•
(Inclusion term) Conditions classifiable to C18
•
(Inclusion term) Conditions classifiable to C7A.026
•
(Inclusion term) Conditions classifiable to C19-C21
•
(Inclusion term) Conditions classifiable to C22
•
(Inclusion term) Conditions classifiable to C7A.01-
•
(Inclusion term) Conditions classifiable to C17
•
(Inclusion term) Conditions classifiable to C25
•
(Inclusion term) Conditions classifiable to C7A.090
•
(Inclusion term) Conditions classifiable to C34
•
(Inclusion term) Conditions classifiable to C33
•
(Inclusion term) Conditions classifiable to C32
•
(Inclusion term) Conditions classifiable to C30-C31
•
(Inclusion term) Conditions classifiable to C7A.091
•
(Inclusion term) Conditions classifiable to C37
•
(Inclusion term) Conditions classifiable to C50.-
•
(Inclusion term) Conditions classifiable to C51-C63
•
(Inclusion term) Conditions classifiable to C64-C68
•
(Excludes Type 1) personal history of malignant neoplasm of renal pelvis (Z85.53)
•
(Inclusion term) Conditions classifiable to C7A.093
•
(Inclusion term) Conditions classifiable to C64
•
(Inclusion term) Conditions classifiable to C91-C95
•
(Excludes Type 1) leukemia in remission C91.0-C95.9 with 5th character 1
•
(Inclusion term) Conditions classifiable to C81
•
(Inclusion term) Conditions classifiable to C82-C85
•
(Inclusion term) Conditions classifiable to C88-C90, C96
•
(Excludes Type 1) multiple myeloma in remission (C90.01)
plasma cell leukemia in remission (C90.11)
plasmacytoma in remission (C90.21)
•
(Inclusion term) Conditions classifiable to C00-C14, C40-C49, C69-C75, C7A.098, C76-C79
•
(Inclusion term) Conditions classifiable to C43
•
(Inclusion term) Conditions classifiable to C4A
•
(Inclusion term) Conditions classifiable to C44
•
(Excludes Type 2) personal history of malignant neoplasm of skin (Z85.82-)
•
(Inclusion term) Conditions classifiable to C7A.00, C80.1
•
(Code first) any follow-up examination after treatment (Z09)
•
(Excludes Type 2) personal history of malignant neoplasms (Z85.-)
•
(Inclusion term) Conditions classifiable to D00-D09
•
(Inclusion term) Conditions classifiable to D05
•
(Inclusion term) Conditions classifiable to D06
Personal history of cervical intraepithelial neoplasia III [CIN III]
•
(Inclusion term) Conditions classifiable to D07
Personal history of high-grade prostatic intraepithelial neoplasia III [HGPIN III]
Personal history of vaginal intraepithelial neoplasia III [VAIN III]
Personal history of vulvar intraepithelial neoplasia III [VIN III]
•
(Inclusion term) Conditions classifiable to D00
•
(Inclusion term) Conditions classifiable to D01
Personal history of anal intraepithelial neoplasia (AIN III)
•
(Inclusion term) Conditions classifiable to D02
•
(Inclusion term) Conditions classifiable to D03
•
(Excludes Type 2) sites other than skin - code to personal history of in-situ neoplasm of the site
•
(Inclusion term) Conditions classifiable to D04
Personal history of carcinoma in situ of skin
•
(Inclusion term) Conditions classifiable to D09
•
(Inclusion term) Conditions classifiable to A00-B89, B99
•
(Excludes Type 1) personal history of infectious diseases specific to a body system
sequelae of infectious and parasitic diseases (B90-B94)
•
(Inclusion term) Personal history of MRSA infection
•
(Inclusion term) Conditions classifiable to D50-D89
•
(Inclusion term) Conditions classifiable to E00-E88
•
(Excludes Type 2) current diabetic foot ulcer (E08.621, E09.621, E10.621, E11.621, E13.621)
•
(Inclusion term) Personal history of conditions classifiable to O24.4-
•
(Excludes Type 1) gestational diabetes mellitus in current pregnancy (O24.4-)
•
(Inclusion term) Conditions classifiable to F40-F59
•
(Inclusion term) Conditions classifiable to G00-G99, H00-H95
•
(Inclusion term) Personal history of encephalitis
Personal history of meningitis
•
(Inclusion term) Conditions classifiable to I00-I99
•
(Excludes Type 2) old myocardial infarction (I25.2)
personal history of anaphylactic shock (Z87.892)
postmyocardial infarction syndrome (I24.1)
•
(Inclusion term) Personal history of prolonged reversible ischemic neurological deficit (PRIND)
Personal history of stroke NOS without residual deficits
•
(Excludes Type 1) personal history of traumatic brain injury (Z87.820)
sequelae of cerebrovascular disease (I69.-)
•
(Inclusion term) Personal history of sudden cardiac death successfully resuscitated
•
(Code first) any follow-up examination after treatment (Z09)
•
(Inclusion term) Conditions classifiable to J00-J99
•
(Inclusion term) Conditions classifiable to K00-K93
•
(Inclusion term) Conditions classifiable to L00-L99
•
(Excludes Type 2) personal history of diabetic foot ulcer (Z86.31)
•
(Inclusion term) Conditions classifiable to M00-M99
•
(Excludes Type 2) personal history of (healed) traumatic fracture (Z87.81)
•
(Inclusion term) Personal history of (healed) fragility fracture
Personal history of (healed) collapsed vertebra due to osteoporosis
•
(Inclusion term) Personal history of (healed) collapsed vertebra NOS
•
(Excludes Type 2) personal history of osteoporosis fracture (Z87.310)
•
(Inclusion term) Personal history of (healed) fatigue fracture
•
(Inclusion term) Conditions classifiable to N00-N99
•
(Excludes Type 1) personal history of intraepithelial neoplasia III of female genital tract (Z86.001, Z86.008)
personal history of malignant neoplasm of female genital tract (Z85.40-Z85.44)
•
(Excludes Type 1) personal history of malignant neoplasm of prostate (Z85.46)
•
(Excludes Type 1) personal history of malignant neoplasm of cervix uteri (Z85.41)
•
(Inclusion term) Personal history of kidney stones
•
(Inclusion term) Conditions classifiable to O00-O9A
•
(Excludes Type 2) recurrent pregnancy loss (N96)
•
(Excludes Type 1) current pregnancy with history of pre-term labor (O09.21-)
•
(Inclusion term) Personal history of trophoblastic disease
•
(Inclusion term) Conditions classifiable to Q00-Q89 that have been repaired or corrected
•
(Excludes Type 1) congenital malformations that have been partially corrected or repair but which still require medical treatment - code to condition
•
(Excludes Type 2) other postprocedural states (Z98.-)
personal history of medical treatment (Z92.-)
presence of cardiac and vascular implants and grafts (Z95.-)
presence of other devices (Z97.-)
presence of other functional implants (Z96.-)
transplanted organ and tissue status (Z94.-)
•
(Excludes Type 2) personal history of self harm (Z91.5)
•
(Excludes Type 2) personal history of (healed) nontraumatic fracture (Z87.31-)
•
(Inclusion term) Conditions classifiable to S00-T88, except traumatic fractures
•
(Excludes Type 1) personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (Z86.73)
•
(Excludes Type 1) current nicotine dependence (F17.2-)
•
(Code Also) allergy status such as:
allergy status to drugs, medicaments and biological substances (Z88.-)
allergy status, other than to drugs and biological substances (Z91.0-)
•
(Excludes Type 2) Allergy status, other than to drugs and biological substances (Z91.0-)
•
(Includes) amputation status
postprocedural loss of limb
post-traumatic loss of limb
•
(Excludes Type 1) acquired deformities of limbs (M20-M21)
congenital absence of limbs (Q71-Q73)
•
(Excludes Type 2) acquired absence of thumb (Z89.01-)
•
(Inclusion term) Disarticulation at wrist
•
(Inclusion term) Acquired absence of arm NOS
•
(Inclusion term) Disarticulation at elbow
•
(Inclusion term) Acquired absence of shoulder joint following explantation of shoulder joint prosthesis, with or without presence of antibiotic-impregnated cement spacer
•
(Excludes Type 2) acquired absence of great toe (Z89.41-)
•
(Inclusion term) Disarticulation of ankle
•
(Inclusion term) Acquired absence of knee joint following explantation of knee joint prosthesis, with or without presence of antibiotic-impregnated cement spacer
•
(Inclusion term) Acquired absence of leg NOS
Disarticulation at knee
•
(Inclusion term) Acquired absence of hip joint following explantation of hip joint prosthesis, with or without presence of antibiotic-impregnated cement spacer
Disarticulation at hip
•
(Includes) postprocedural or post-traumatic loss of body part NEC
•
(Excludes Type 1) congenital absence - see Alphabetical Index
•
(Excludes Type 2) postprocedural absence of endocrine glands (E89.-)
•
(Inclusion term) Acquired absence of nose
•
(Excludes Type 2) teeth (K08.1)
•
(Code Also) exocrine pancreatic insufficiency (K86.81)
•
(Use additional code) code to identify any associated:
diabetes mellitus, postpancreatectomy (E13.-)
insulin use (Z79.4)
•
(Inclusion term) Acquired absence of pancreas NOS
•
(Inclusion term) Acquired absence of bladder
•
(Excludes Type 1) personal history of sex reassignment (Z87.890)
•
(Excludes Type 2) female genital mutilation status (N90.81-)
•
(Inclusion term) Acquired absence of uterus NOS
Status post total hysterectomy
•
(Inclusion term) Status post partial hysterectomy with remaining cervical stump
•
(Excludes Type 2) contact with and (suspected) exposures hazardous to health (Z77.-)
exposure to pollution and other problems related to physical environment (Z77.1-)
female genital mutilation status (N90.81-)
personal history of physical injury and trauma (Z87.81, Z87.82-)
occupational exposure to risk factors (Z57.-)
•
(Excludes Type 2) Allergy status to drugs, medicaments, and biological substances (Z88.-)
•
(Excludes Type 2) food additives allergy status (Z91.02)
•
(Excludes Type 1) lactose intolerance (E73.-)
•
(Inclusion term) Allergy to shellfish
Allergy to octopus or squid ink
•
(Inclusion term) Allergy to nuts other than peanuts
•
(Inclusion term) Latex sensitivity status
•
(Inclusion term) Allergy status to contrast media used for diagnostic X-ray procedure
•
(Code first) underdosing of medication (T36-T50) with fifth or sixth character 6
•
(Excludes Type 1) adverse effect of prescribed drug taken as directed- code to adverse effect
poisoning (overdose) -code to poisoning
•
(Code first) underdosing of medication (T36-T50) with fifth or sixth character 6
•
(Excludes Type 1) adverse effect of prescribed drug taken as directed- code to adverse effect
poisoning (overdose) -code to poisoning
•
(Inclusion term) Patient's underdosing of medication NOS
•
(Inclusion term) Nonadherence to medical treatment
•
(Excludes Type 2) personal history of abuse in childhood (Z62.81-)
•
(Excludes Type 1) current adult physical abuse (T74.11, T76.11)
current adult sexual abuse (T74.21, T76.11)
•
(Excludes Type 1) current adult neglect (T74.01, T76.01)
•
(Inclusion term) Personal history of parasuicide
Personal history of self-poisoning
Personal history of suicide attempt
•
(Inclusion term) At risk for falling
•
(Inclusion term) Individual (civilian or military) with past history of military war, peacekeeping and humanitarian deployment (current or past conflict)
Returned from military deployment
•
(Code first) underlying disorder such as:
Alzheimer's disease (G30.-)
autism or pervasive developmental disorder (F84.-)
intellectual disabilities (F70-F79)
unspecified dementia with behavioral disturbance (F03.9-)
•
(Excludes Type 2) postprocedural states (Z98.-)
•
(Excludes Type 1) counseling or management of current contraceptive practices (Z30.-)
long term (current) use of contraception (Z79.3)
presence of (intrauterine) contraceptive device (Z97.5)
•
(Excludes Type 2) long term (current) drug therapy (Z79.-)
•
(Inclusion term) Personal history of steroid therapy NOS
•
(Excludes Type 2) personal history of steroid therapy (Z92.24)
•
(Inclusion term) Personal history of exposure to therapeutic radiation
•
(Excludes Type 1) exposure to radiation in the physical environment (Z77.12)
occupational exposure to radiation (Z57.1)
•
(Code first) condition requiring tPA administration, such as:
acute cerebral infarction (I63.-)
acute myocardial infarction (I21.-, I22.-)
•
(Inclusion term) Personal history of failed conscious sedation
•
(Excludes Type 2) failed moderate sedation during procedure (T88.52)
•
(Excludes Type 2) unintended awareness under general anesthesia during procedure (T88.53)
•
(Excludes Type 1) artificial openings requiring attention or management (Z43.-)
complications of external stoma (J95.0-, K94.-, N99.5-)
•
(Inclusion term) Nephrostomy status
Ureterostomy status
Urethrostomy status
•
(Includes) organ or tissue replaced by heterogenous or homogenous transplant
•
(Excludes Type 1) complications of transplanted organ or tissue - see Alphabetical Index
•
(Excludes Type 2) presence of vascular grafts (Z95.-)
•
(Excludes Type 1) artificial heart status (Z95.812)
heart-valve replacement status (Z95.2-Z95.4)
•
(Inclusion term) Autogenous skin transplant status
•
(Excludes Type 2) complications of cardiac and vascular devices, implants and grafts (T82.-)
•
(Inclusion term) Presence of cardiac resynchronization therapy (CRT-P) pacemaker
•
(Excludes Type 1) adjustment or management of cardiac device (Z45.0-)
adjustment or management of cardiac pacemaker (Z45.0)
presence of automatic (implantable) cardiac defibrillator with synchronous cardiac pacemaker (Z95.810)
•
(Inclusion term) Presence of coronary artery bypass graft
•
(Inclusion term) Presence of heart valve NOS
•
(Excludes Type 1) coronary angioplasty status without implant and graft (Z98.61)
•
(Inclusion term) Presence of automatic (implantable) cardiac defibrillator with synchronous cardiac pacemaker
Presence of cardiac resynchronization therapy defibrillator (CRT-D)
Presence of cardioverter-defibrillator (ICD)
•
(Excludes Type 1) peripheral vascular angioplasty without implant and graft (Z98.62)
•
(Inclusion term) Presence of intravascular prosthesis NEC
•
(Excludes Type 2) complications of internal prosthetic devices, implants and grafts (T82-T85)
fitting and adjustment of prosthetic and other devices (Z44-Z46)
•
(Inclusion term) Presence of pseudophakia
•
(Inclusion term) Presence of bone-conduction hearing device
Presence of eustachian tube stent
Stapes replacement
•
(Inclusion term) Hip-joint replacement (partial) (total)
•
(Inclusion term) Presence of skull plate
•
(Inclusion term) Presence of brain neurostimulator
Presence of gastric neurostimulator
Presence of peripheral nerve neurostimulator
Presence of sacral nerve neurostimulator
Presence of spinal cord neurostimulator
Presence of vagus nerve neurostimulator
•
(Excludes Type 1) complications of internal prosthetic devices, implants and grafts (T82-T85)
•
(Excludes Type 2) fitting and adjustment of prosthetic and other devices (Z44-Z46)
presence of cerebrospinal fluid drainage device (Z98.2)
•
(Inclusion term) Presence of dentures (complete) (partial)
•
(Excludes Type 1) checking, reinsertion or removal of implantable subdermal contraceptive (Z30.46)
checking, reinsertion or removal of intrauterine contraceptive device (Z30.43-)
•
(Excludes Type 2) aftercare (Z43-Z49, Z51)
follow-up medical care (Z08-Z09)
postprocedural complication - see Alphabetical Index
•
(Excludes Type 2) bariatric surgery status (Z98.84)
gastric bypass status (Z98.84)
obesity surgery status (Z98.84)
•
(Inclusion term) Presence of CSF shunt
•
(Code first) underlying disease
•
(Use additional code) code to identify intraocular lens implant status (Z96.1)
•
(Excludes Type 1) aphakia (H27.0)
•
(Excludes Type 1) female infertility (N97.-)
male infertility (N46.-)
•
(Excludes Type 1) coronary angioplasty status with implant and graft (Z95.5)
•
(Excludes Type 1) peripheral vascular angioplasty status with implant and graft (Z95.820)
•
(Inclusion term) Dental crown status
Dental fillings status
•
(Excludes Type 1) breast implant removal status (Z98.86)
•
(Excludes Type 1) Inflammation (infection) of postprocedural bleb (H59.4-)
•
(Inclusion term) Gastric banding status
Gastric bypass status for obesity
Obesity surgery status
•
(Excludes Type 1) bariatric surgery status complicating pregnancy, childbirth, or the puerperium (O99.84)
•
(Excludes Type 2) intestinal bypass and anastomosis status (Z98.0)
•
(Inclusion term) Transplanted organ previously removed due to complication, failure, rejection or infection
•
(Excludes Type 1) encounter for removal of transplanted organ -code to complication of transplanted organ (T86.-)
•
(Excludes Type 2) complications from in utero procedure for current pregnancy (O35.7)
supervision of current pregnancy with history of in utero procedure during previous pregnancy (O09.82-)
•
(Inclusion term) Personal history of surgery, not elsewhere classified
•
(Excludes Type 1) Maternal care due to uterine scar from previous surgery (O34.2-)
•
(Excludes Type 1) cardiac pacemaker status (Z95.0)
•
(Inclusion term) Dependence on ventilator
•
(Excludes Type 1) mechanical complication of respirator [ventilator] (J95.850)
•
(Inclusion term) Hemodialysis status
Peritoneal dialysis status
Presence of arteriovenous shunt for dialysis
Renal dialysis status NOS
•
(Excludes Type 1) encounter for fitting and adjustment of dialysis catheter (Z49.0-)
•
(Excludes Type 2) noncompliance with renal dialysis (Z91.15)
•
(Inclusion term) Wheelchair confinement status
•
(Code first) cause of dependence, such as:
muscular dystrophy (G71.0-)
obesity (E66.-)
•
(Inclusion term) Dependence on long-term oxygen
•
(Inclusion term) Dependence on machine or device NOS