Z38.6

ICD-10-CM Official Guidelines for Coding and Reporting, quoted in full. Published by CMS and NCHS; in the public domain.

I.B.3 Code or codes from A00.0 through T88.9, Z00-Z99.8, U00-U85 names this code p.13

The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit.

I.C.16.a.2 Principal Diagnosis for Birth Record names this code p.71

When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. A code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital. A code from category Z38 is used only on the newborn record, not on the mother’s record.

I.C.16.b.2 Z05 on other than the birth record names this code p.73

A code from category Z05 may also be assigned as a principal or first- listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.

I.C.16.b.3 Z05 on a birth record names this code p.73

A code from category Z05 is to be used as a secondary code after the code from category Z38, Liveborn infants according to place of birth and type of delivery.

I.C.16.h COVID-19 Infection in Newborn names this code p.74

For a newborn that tests positive for COVID-19, assign code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) in neonates/newborns in the absence of documentation indicating a specific type of transmission. For a newborn that tests positive for COVID-19 and the provider documents the condition was contracted in utero or during the birth process, assign codes P35.8, Other congenital viral diseases, and U07.1, COVID-19. When coding the birth episode in a newborn record, the appropriate code from category Z38, Liveborn infants according to place of birth and type of delivery, should be assigned as the principal diagnosis.

I.C.17 Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-QA1) names this code p.74

Assign an appropriate code(s) from categories Q00-QA1, Congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented. A malformation/deformation/or chromosomal abnormality may be the principal/first-listed diagnosis on a record or a secondary diagnosis. When a malformation/deformation or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any manifestations that may be present. When the code assignment specifically identifies the malformation/deformation or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are not an inherent component. Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, a malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-QA1. For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00- QA1.

I.C.20.a.1 Used with any code in the range of A00.0-T88.9, Z00-Z99 names this code p.88

An external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that represents a health condition due to an external cause. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as a heart attack that occurs during strenuous physical activity.

I.C.21 Chapter 21: Factors influencing health status and contact with health names this code p.92

services (Z00-Z99) Note: The chapter specific guidelines provide additional information about the use of Z codes for specified encounters.

I.C.21.c.6 Observation names this code p.98

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 primarily to be used as a principal/first-listed diagnosis. An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis. Also, 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. Codes from subcategory Z03.7, Encounter for suspected maternal and fetal conditions ruled out, may either be used as a first-listed or as an additional code assignment depending on the case. They are for use in very limited circumstances on a maternal record when an encounter is for a suspected maternal or fetal condition that is ruled out during that encounter (for example, a maternal or fetal condition may be suspected due to an abnormal test result). These codes should not be used when the condition is confirmed. In those cases, the confirmed condition should be coded. In addition, these codes are not for use if an illness or any signs or symptoms related to the suspected condition or problem are present. In such cases the diagnosis/symptom code is used. Additional codes may be used in addition to the code from subcategory Z03.7, but only if they are unrelated to the suspected condition being evaluated. Codes from subcategory Z03.7 may not be used for encounters for antenatal screening of mother. See Section I.C.21. Screening. For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category O35, O36, O40 or O41. 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

I.C.21.c.15 Z Codes That May Only be Principal/First-Listed Diagnosis names this code p.105

The following Z codes/subcategories/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 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 Z40 Encounter for prophylactic surgery 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

I.C.21.c.16 Newborns and Infants names this code p.106

See Section I.C.16. Newborn (Perinatal) Guidelines, for further instruction on the use of these codes. Newborn Z codes/subcategories/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

IV.B Codes from A00.0 through T88.9, Z00-Z99, U00-U85 names this code p.113

The appropriate code(s) from A00.0 through T88.9, Z00-Z99 and U00-U85 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.

IV.E Encounters for circumstances other than a disease or injury names this code p.113

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00- Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. See Section I.C.21. Factors influencing health status and contact with health services.

I.C.21.a Use of Z Codes in Any Healthcare Setting chapter guidance p.92

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.

I.C.21.b Z Codes Indicate a Reason for an Encounter or Provide chapter guidance p.93

Additional Information about a Patient Encounter Z codes are not procedure codes. A corresponding procedure code must accompany a Z code to describe any procedure performed.

I.C.21.c.1 Contact/Exposure chapter guidance p.93

Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who are suspected to have been exposed to a disease 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.

I.C.21.c.2 Inoculations and vaccinations chapter guidance p.93

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.

I.C.21.c.3 Status chapter guidance p.93

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 a history 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. The status Z codes/categories are: Z14 Genetic carrier Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease. Z15 Genetic susceptibility to disease Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease. Codes from category Z15 should generally not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Additional codes should be assigned for any applicable family or personal history. Z16 Resistance to antimicrobial drugs This category indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first. Z17 Estrogen, and other hormones and factors receptor status Z18 Retained foreign body fragments Z19 Hormone sensitivity malignancy status Z21 Asymptomatic HIV infection status This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease. Z22 Carrier of infectious disease Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. Z28.3 Underimmunization status See Section I.B.14. for underimmunization documentation by clinicians other than the patient’s provider. Z33.1 Pregnant state, incidental This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required. Z66 Do not resuscitate This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Z67 Blood type Z68 Body mass index (BMI) BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity or anorexia) documented by the patient’s provider. Do not assign BMI codes during pregnancy. When the documentation reflects fluctuating BMI values during the current encounter for an associated reportable condition, assign a code for the most severe value. See Section I.B.14. for BMI documentation by clinicians other than the patient’s provider. Z74.01 Bed confinement status Z76.82 Awaiting organ transplant status Z78 Other specified health status Code Z78.1, Physical restraint status, may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. Please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure. Z79 Long-term (current) drug therapy Codes from this category indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug use, abuse, or dependence instead. Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis). Z88 Allergy status to drugs, medicaments and biological substances Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status Z89 Acquired absence of limb Z90 Acquired absence of organs, not elsewhere classified Z91.0- Allergy status, other than to drugs and biological substances Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility Assign code Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility. This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility. The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first. Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record. 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 Assign code Z98.85, Transplanted organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter. See section I.C.19. for information on the coding of organ transplant complications. Z99 Dependence on enabling machines and devices, not elsewhere classified Note: Categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.

I.C.21.c.4 History (of) chapter guidance p.97

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. The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es). 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 Z91.81 History of falling Z91.82 Personal history of military deployment Z91.85 Personal history of military service 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

I.C.21.c.5 Screening chapter guidance p.98

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. 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

I.C.21.c.7 Aftercare chapter guidance p.99

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. The aftercare Z codes should also not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate 7 character (for subsequent encounter). The aftercare codes are generally first listed to explain the specific reason for the encounter. An aftercare code may be reported as an additional code when a specific type of aftercare is provided in addition to the reason for the encounter. An example of this would be the closure of a colostomy during an encounter for treatment of another condition. Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. The sequencing of multiple aftercare codes depends on the circumstances of the encounter. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. For example, code Z95.1, Presence of aortocoronary bypass graft, may be used with code Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed. A status code should not be used when the aftercare code indicates the type of status, such as using Z43.0, Encounter for attention to tracheostomy, with Z93.0, Tracheostomy status. The aftercare codes are generally found in the following categories: 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 care

I.C.21.c.8 Follow-up chapter guidance p.100

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 7 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 codes/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 Codes Z08, Encounter for follow-up examination after completed treatment for malignant neoplasm, and Z09, Encounter for follow up examination after completed treatment for conditions other than malignant neoplasm, may be assigned following any type of completed treatment modality (including both medical and surgical treatments). Z39 Encounter for maternal postpartum care and examination

I.C.21.c.10 Counseling chapter guidance p.101

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. The counseling Z codes/categories: Z30.0- Encounter for general counseling and advice on contraception Z31.5 Encounter for procreative 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 Note: Code Z71.84, Encounter for health counseling related to travel, is to be used for health risk and safety counseling for future travel purposes. Code Z71.85, Encounter for immunization safety counseling, is to be used for counseling of the patient or caregiver regarding the safety of a vaccine. This code should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the administration of vaccines. Code Z71.87, Encounter for pediatric-to-adult transition counseling, should be assigned when pediatric-to-adult transition counseling is the sole reason for the encounter or when this counseling is provided in addition to other services, such as treatment of a chronic condition. If both transition counseling and treatment of a medical condition are provided during the same encounter, the code(s) for the medical condition(s) treated and code Z71.87 should be assigned, with sequencing depending on the circumstances of the encounter. Z76.81 Expectant mother prebirth pediatrician visit

I.C.21.c.9 Donor chapter guidance p.101

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 for individuals donating for others, as well as for self-donations. They are not used to identify cadaveric donations.

Risk adjustment

This code