Abbreviation for ICD-10-CM codes that identify factors that influence health status and encounters that are not due to illness or injury. Chapter 21 contains Z codes that are used to report encounters for circumstances other than a disease or injury, such as factors influencing health status, and to describe the nature of a patient's contact with health services. There are two main types: (1) reporting visits with healthy (or ill) patients who receive services other than treatments, such as annual checkups, immunizations, and normal childbirth. This use is coded by a Z code that identifies the service, such as Z00.01 Encounter for general adult medical examination with abnormal findings; and (2) Reporting encounters in which a problem not currently affecting the patient's health status needs to be noted, such as personal and family history. For example, a person with a family history of breast cancer is at higher risk for the disease, and a Z code is assigned as an additional code for screening codes to explain the need for a test or procedure such as Z80.3 Family history of malignant neoplasm of breast.
Use Z codes to show medical necessity. Z codes such as family history or a patient's previous condition help demonstrate why a service was medically necessary.
A Z code can be used as EITHER a primary code for an encounter or as an additional code. It is researched in the same way as other codes, using the Alphabetic Index to point to the term's code and the Tabular List to verify it. The terms that indicate the need for Z codes, are NOT the same as other medical terms. They usually have to do with a reason for an encounter other than a disease or its complications. When found in diagnostic statements the words "contact/exposure," "contraception," "counseling," "examination," "fitting of," "follow-up," "history (of)," "screening/test," "status,"
"supervision (of)," or "vaccination/inoculation" often point to Z codes.