Today we're going to talk about factors
influencing health status and contact
with health services and these are our Z
codes. We've used them in several of our
coding scenarios this semester, so on
this podcast, we'll just talk about a few
of those that aren't as common and
we'll also look at some of the
guidelines. One thing I've noticed about Z
codes is how many different main terms
take you to the Z codes and also how
confusing your documentation can be. For
example, your documentation might say
encounter for examination of something
but when you go to "encounter", it's not
there. You have to go to "examination" to
find it. Similar to some of the other
coding scenarios we've had, you do have
to look around a little bit but I
suggest that you look at your coding
guidelines for Chapter 21. Look at the
headings of the various sections of the
coding guidelines for that chapter and
those headings are also main terms where
you might find codes. If you have any
trouble remembering this (list of main terms used to find Z codes), I would put it
somewhere in your code book because you
will be often using Z codes and need to
be able to look them up quickly.
Depending on the type of coder you are,
for example, if you're an outpatient coder
or coding in a physician's office, you're
going to use some of these Z codes a lot
more often than might someone in the
hospital. Z codes used as a principal or
the first listed (diagnosis)-as a reminder the
principal diagnosis is that condition
chiefly responsible for someone's
admission to the hospital. It is a
hospital admission diagnosis. The first
listed diagnosis is the reason for the
encounter, so it is a diagnosis that is going
to be used at the physician office
setting. Z codes can be used to indicate
that a person with a resolving disease
or injury or a chronic condition is
being seen for specific aftercare, such
as the removal of fixation devices like
orthopedic pins. We also use Z codes as
a principal (diagnosis) when the patient is being
seen solely to receive radiotherapy,
chemotherapy or immunotherapy. We use Z
codes when the person is not ill and
is coming to healthcare for a specific
reason, whether it's to get counseling or
examination and to indicate the birth
status of newborns (Z38.-). As a reminder, here is
something that we've looked at earlier
this semester. We have a term birth,
caesarean delivery and you see that the
Z38.01 code is the principal (diagnosis) and
following our coding guideline here on
the right, (we are) assigning a code from
category Z38 as the principal diagnosis on a
newborn's record. Here's an example
of that case when the patient has been
admitted solely for the administration
of the chemo and immunotherapy. Either of
these two things could be the principal diagnosis
and I also have coded the leukemia here
and you can see the pathway on the right.
At the bottom, I put just a little note
about these immunotherapy and chemotherapy
agents. The Z codes might also be used as
additional diagnoses. They are used in
that situation when a patient has a
history, a health status, or some problem
that is not in itself an illness
or an injury, but it may influence
patient care. What comes to my mind is
someone is a status post cardiovascular
bypass (CABG) or there's times when
status post joint replacement would be
significant, status post a cardiovascular
surgery, etc. These additional diagnosis codes
can be the principal (diagnosis) if the fact of the
history itself is the reason for the
admission. I've given here some
personal history codes and a family
history codes. Z codes are used to
indicate the outcome of delivery. Here's
an example of a Z code as an additional
diagnosis when we've got the "pregnancy
complicated by (elderly primigravida)"
as your principal (diagnosis) because that's why
she's in the hospital. You also have the
outcome of delivery (Z37.0) and the
Z3A.40 (weeks of gestation). Now you notice that on the
mother's chart, the outcome of delivery
is not the principal (diagnosis). Whatever brought her
into the hospital is what's (assigned as) the
principal diagnosis (for the mother) but on the baby's chart, the
outcome of birth (Z38-) is the principal diagnosis.
Here's another example of using a Z code
as an additional diagnosis and this is
taken from a patient falling, with a
history of falling. In this case, we
are going to have both repeated falls
R29.6 and the history of falls Z91.81.
The patient has both (diagnoses)
and the guideline tell us we can use both.
Admission or encounter for aftercare
management- there's several examples of
aftercare that are given in your book
and I've just put a few here. Here's
an example. Encounter for gastrostomy
tube irrigation. Now even though it says
"encounter for", when you go to the
Alphabetical Index, you're not going to
find gastrostomy irrigation under
"encounter" but if you can think about (a gastrostomy being an)
artificial opening and whenever someone
is changing a dressing or irrigating
it, giving attention to it so that one is
a little bit easier to remember, for
me than other ones but this one is an
example of the gastrostomy tube
irrigation. Here's an example of
palliative care, when the patient's
made to hospice and the palliative care
diagnosis is first because that is why
he was admitted to the hospice residence. Then
the (code for the) brain cancer is next.
It is important to remember that aftercare Z
codes are not used for aftercare for
fractures. That is where that 7th
character comes in. Remember all the
7th characters that we used.
Aftercare is the (7th character) "D" for a subsequent
encounter (7th character ). You have to
remember that, with some of
those codes, you have more options than
just "D". You have a subsequent encounter
with delayed healing non-union and (subsequent encounter with delayed healing with) malunion.
They give you a different 7th
character, but in any case these are used
instead of aftercare Z codes. There are
aftercare Z codes, for example, for joint
replacement but you would not use an
aftercare Z code for a fracture. Here's an
example of the aftercare for a fracture.
We have a broken radius and we're going
to use the 6th character of "G" for
delayed healing, subsequent encounter
with delayed healing and no Z code for
the aftercare of a fracture. We can also
use Z08, Z09 and Z39 for the principal (diagnosis) if
the patient is admitted for the purpose
of surveillance after an initial
treatment has been completed. Here's an
example. The patient has a surgical
excision of a malignant neoplasm of the
ovary followed by chemo and is being
admitted now for follow-up. No evidence
of recurrence or metastasis and no other
pathological condition is identified, so
the principal (diagnosis) is going to be the
follow-up examination, following the
malignant neoplasm. We're going to
put a history of the personal malignant
neoplasm of the ovary because it's no
longer there. She's had it excised and
there's no evidence of any recurrence so
we can do a "history of" (code). If she still had
evidence of the ovarian cancer or
had not completed her chemo, for example,
you would use the malignancy diagnosis.
not the "history of". The history of the
malignant neoplasm can only be
used once the person has completed his/her
treatment.
We can use Z01 for encounters for
preprocedural examination. Here's an example
of patient with diagnosis of cholelithiasis,
referred to radiology for pre-op chest
x-ray. You see there we chose the sub
terms "specified" and I have a note you
can look in your Tabular and see there
are sub terms under "preprocedural" for
cardiovascular, respiratory, and specified.
We know from our diagnostic statement we
are addressing the cholelithiasis.
I see an error here but I can't correct it.
So we chose to
specify because neither the
cardiovascular or the respiratory is
correct in this case. We're also
going to code the gallbladder
stones because those are still there. He
hasn't had the surgery yet to remove
those. There are codes for admission for
observation and evaluation and here's
two examples given here. These are
used when there's no sign or symptom,
there's no injury or illness really, very
little to code based on the fact you
need an examination. I thought the
example that they've given in the book
is a good one where the policeman is
asking for evaluation and it's done and
no problem has been found. So we have to
have something to code so we're going to
code just a psychiatric examination
requested by the authority as our
principal diagnosis, our only diagnosis
really. Z11 - Z13 are encounters
for screening. The case I've given here
is an asymptomatic patient having a
screening mammography. On the
mammogram, the radiologist found a micro
calcification of the breast so we're
going to code the screening first (Z12.31)
and I have there the pathway.
It might be a little bit different than
you might think for how you would get to
that Z code. The microcalcifications
are the R92.0 code.
We also have Z codes that represent
patient history, status or any problems
that they're having. It's important
for you to know the distinction between
a "history", which is when a condition no
longer exists, and a "status" when the
condition is still present. You're
going to code those accordingly. Z79 is
the category where a patient's
continuous long-term use of a prescribed
drug is indicated. This would not be used
in those cases where, say someone comes
into the emergency department and they
give them insulin to kind of get the
blood sugar down. It's not a long-term
chronic use (of a drug) so you would not use a Z79
code but if someone comes in who has
been using insulin for some time to
control diabetes, yes, you would use it in
that case. There's many other long-term
prescribed uses (the anticoagulant. the
steroid. the antibiotic therapy. and other
ones in the Tabular you might look at.
Z80 - Z84 is a "family history" of
different things and Z85-Z92 is a
"personal history". When you look in
the Alphabetical Index, you would notice
that the "family history" comes before the
"personal history" because of the
alphabetic sequence there.
Z88 -Z99 The patient has a continuing
condition that may influence care. We'll
look at a few of those. It's also
important to note when not to use a Z
code. You don't add a Z code to a list of
code assignments unless the Z code
provides additional information that is
not available to the reader anywhere
else. The example that was given is a
patient with the rejection of a
transplanted kidney is in the hospital.
Well, the fact that he's rejecting
a transplanted kidney is contained in
the T86.11 code so you would not need
another code as Z94.0 code
saying yep this person's got a kidney
transplant because your first code took
care of that.
It's important to document patient
non-compliance for a couple of reasons.
What is it does help those who keep
statistics of those sorts of things and
it also protects the hospital or the
physician and/or the physician when it
can be proven that the hospital or the
physician tried to provide what the
patient needed and for whatever reason,
the patient did not comply. Some
things that come into play here are
economic or job concerns, social
maladjustment, any kind of housing
problems, those can all affect a
patient's compliance. There are many
codes under Z15 (category code) that are used for
genetic susceptibility to disease.
For example
if a patient is saying, "I want to
have a mammogram because my mother been
diagnosed with breast cancer and I've
never had a mammogram", the coder might
capture that in Z15.01 that the
patient's genetic susceptibility to
breast cancer would be a good reason to
have that mammogram. There's several
there given as well as some in the
book. I haven't addressed all of the
guidelines or all of the possibilities
for the Z codes. I encourage you to go to
Chapter 21, read through those. You will
use them quite a bit and I hope you're
(already) a little bit familiar with them because of
the work we've been doing this semester.
Thank you so much. If you have any
questions, please let me know. Have a good day.