ICD-10-CM (2010)/CHAPTER 21

Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances

Z66 Do not resuscitate [DNR] status

Z67 Blood type

Z68 Body mass index (BMI)

Z69-Z76 Persons encountering health services in other circumstances

Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status

Persons encountering health services for examinations (Z00-Z13)

Note: Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.

Excludes1: examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)

Z00 Encounter for general examination without complaint, suspected or reported diagnosis

Excludes1: encounter for examination for administrative purposes (Z02.-)

Excludes2: encounter for pre-procedural examinations (Z01.81-)

special screening examinations (Z11-Z13)

Z00.0 Encounter for general adult medical examination

Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations

Excludes1: encounter for examination of sign or symptom- code to sign or symptom

general health check-up of infant or child (Z00.12.-)

Z00.00 Encounter for general adult medical examination without abnormal findings

Encounter for adult health check-up NOS

Z00.01 Encounter for general adult medical examination with abnormal findings

Use additional code to identify abnormal findings

Z00.1 Encounter for newborn, infant and child health examinations

Z00.11 Newborn health examination

Health check for child under 29 days old

Use additional code to identify any abnormal findings

Excludes1: health check for child over 28 days old (Z00.12-)

Z00.110 Health examination for newborn under 8 days old

Health check for newborn under 8 days old

Z00.111 Health examination for newborn 8 to 28 days old

Health check for newborn 8 to 28 days old

Newborn weight check

Z00.12 Encounter for routine child health examination

Encounter for development testing of infant or child

Health check (routine) for child over 28 days old

Excludes1: health check for child under 29 days old (Z0.11-)

health supervision of foundling or other healthy infant or child (Z76.1-Z76.2)

newborn health examination (Z00.11-)

Z00.121 Encounter for routine child health examination with abnormal findings

Use additional code to identify abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Encounter for routine child health examination NOS

Z00.2 Encounter for examination for period of rapid growth in childhood

Z00.3 Encounter for examination for adolescent development state

Encounter for puberty development state

Z00.5 Encounter for examination of potential donor of organ and tissue

Z00.6 Encounter for examination for normal comparison and control in clinical research program

Z00.7 Encounter for examination for period of delayed growth in childhood

Z00.70 Encounter for examination for period of delayed growth in childhood without abnormal findings

Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal findings

Use additional code to identify abnormal findings

Z00.8 Encounter for other general examination

Encounter for health examination in population surveys

Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

Includes: routine examination of specific system

Note: Codes from category Z01 represent the reason for the encounter. A separate procedure code is required to identify any examinations or procedures performed

Excludes1: 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)

Excludes2: screening examinations (Z11-Z13)

Z01.0 Encounter for examination of eyes and vision

Excludes1: examination for driving license (Z02.4)

Z01. z01.00 Encounter for examination of eyes and vision without abnormal findings

Encounter for examination of eyes and vision NOS

Z01.01 Encounter for examination of eyes and vision with abnormal findings

Use additional code to identify abnormal findings

Z01.1 Encounter for examination of ears and hearing

Z01.10 Encounter for examination of ears and hearing without abnormal findings

Encounter for examination of ears and hearing NOS

Z01.11 Encounter for examination of ears and hearing with abnormal findings

Z01.110 Encounter for hearing examination following failed hearing screening

Z01.118 Encounter for examination of ears and hearing with other abnormal findings

Use additional code to identify abnormal findings

Z01.12 Encounter for hearing conservation and treatment

Z01.2 Encounter for dental examination and cleaning

Z01.20 Encounter for dental examination and cleaning without abnormal findings

Encounter for dental examination and cleaning NOS

Z01.21 Encounter for dental examination and cleaning with abnormal findings

Use additional code to identify abnormal findings

Z01.3 Encounter for examination of blood pressure

Z01.30 Encounter for examination of blood pressure without abnormal findings

Encounter for examination of blood pressure NOS

Z01.31 Encounter for examination of blood pressure with abnormal findings

Use additional code to identify abnormal findings

Z01.4 Encounter for gynecological examination

Excludes2: pregnancy examination or test (Z32.0-)

routine examination for contraceptive maintenance (Z30.4)

Z01.41 Encounter for routine gynecological examination

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:

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-)

Excludes1: gynecologic examination status-post hysterectomy for malignant condition (Z08)

screening cervical pap smear not a part of a routine gynecological examination (Z12.4)

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Use additional code to identify abnormal findings

Z01.42 Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear

Z01.8 Encounter for other specified special examinations

Z01.81 Encounter for preprocedural examinations

Encounter for preoperative examinations

Encounter for radiological and imaging examinations as part of preprocedural examination

Z01.810 Encounter for preprocedural cardiovascular examination

Z01.811 Encounter for preprocedural respiratory examination

Z01.812 Encounter for preprocedural laboratory examination

Blood and urine tests prior to treatment or procedure

Z01.818 Encounter for other preprocedural examination

Encounter for preprocedural examination NOS

Encounter for examinations prior to antineoplastic chemotherapy

Z01.82 Encounter for allergy testing

Excludes1: encounter for antibody response examination (Z01.84)

Z01.83 Encounter for blood typing

Encounter for Rh typing

Z01.84 Encounter for antibody response examination

Encounter for immunity status testing

Excludes1: encounter for allergy testing (Z01.82)

Z01.89 Encounter for other specified special examinations

Z02 Encounter for administrative examination

Z02.0 Encounter for examination for admission to educational institution

Encounter for examination for admission to preschool (education)

Encounter for examination for re-admission to school following illness or medical treatment

Z02.1 Encounter for pre-employment examination

Z02.2 Encounter for examination for admission to residential institution

Excludes1: examination for admission to prison (Z02.8)

Z02.3 Encounter for examination for recruitment to armed forces

Z02.4 Encounter for examination for driving license

Z02.5 Encounter for examination for participation in sport

Excludes1: blood-alcohol and blood-drug test (Z02.83)

Z02.6 Encounter for examination for insurance purposes

Z02.7 Encounter for issue of medical certificate

Excludes1: encounter for general medical examination (Z00-Z01, Z02.0-Z02.6, Z02.8-Z02.9, )

Z02.71 Encounter for disability determination

Encounter for issue of medical certificate of incapacity

Encounter for issue of medical certificate of invalidity

Z02.79 Encounter for issue of other medical certificate

Z02.8 Encounter for other administrative examinations

Z02.81 Encounter for paternity testing

Z02.82 Encounter for adoption services

Z02.83 Encounter for blood-alcohol and blood-drug test

Use additional code for findings of alcohol or drugs in blood (R78.-)

Z02.89 Encounter for other administrative examinations

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

Excludes1: health supervision of foundling or other healthy infant or child (Z76.1-Z76.2)

Z02.9 Encounter for administrative examinations, unspecified

Z03 Encounter for medical observation for suspected diseases and conditions ruled out

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.

Excludes1: contact with and (suspected) exposures hazardous to health (Z77.-)

newborn observation for suspected condition, ruled out (P00-P04)

person with feared complaint in whom no diagnosis is made (Z71.1)

signs or symptoms under study- code to signs or symptoms

Z03.6 Encounter for observation for suspected toxic effect from ingested substance ruled out

Encounter for observation for suspected adverse effect from drug

Encounter for observation for suspected poisoning

Z03.7 Encounter for suspected maternal and fetal conditions ruled out

Encounter for suspected maternal and fetal conditions not found

Excludes1: known or suspected fetal anomalies affecting management of mother, not ruled out (O26.-, O35.-, O36.-, O40.-, O41.-)

Z03.71 Encounter for suspected problem with amniotic cavity and membrane ruled out

Encounter for suspected oligohydramnios ruled out

Encounter for suspected polyhydramnios ruled out

Z03.72 Encounter for suspected placental problem ruled out

Z03.73 Encounter for suspected fetal anomaly ruled out

Z03.74 Encounter for suspected problem with fetal growth ruled out

Z03.75 Encounter for suspected cervical shortening ruled out

Z03.79 Encounter for other suspected maternal and fetal conditions ruled out

Z03.8 Encounter for observation for other suspected diseases and conditions ruled out

Z03.81 Encounter for observation for suspected exposure to biological agents ruled out

Z03.810 Encounter for observation for suspected exposure to anthrax ruled out

Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out

Z03.89 Encounter for observation for other suspected diseases and conditions ruled out

Z04 Encounter for examination and observation for other reasons

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.

Z04.1 Encounter for examination and observation following transport accident

Excludes1: encounter for examination and observation following work accident (Z04.2)

Z04.2 Encounter for examination and observation following work accident

Z04.3 Encounter for examination and observation following other accident

Z04.4 Encounter for examination and observation following alleged rape

Encounter for examination and observation of victim following alleged rape

Encounter for examination and observation of victim following alleged sexual abuse

Z04.41 Encounter for examination and observation following alleged adult rape

Suspected adult rape, ruled out

Suspected adult sexual abuse, ruled out

Z04.42 Encounter for examination and observation following alleged child rape

Suspected child rape, ruled out

Suspected child sexual abuse, ruled out

Z04.6 Encounter for general psychiatric examination, requested by authority

Z04.7 Encounter for examination and observation following alleged physical abuse

Z04.71 Encounter for examination and observation following alleged adult physical abuse

Suspected adult physical abuse, ruled out

Excludes1: 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.-)

Z04.72 Encounter for examination and observation following alleged child physical abuse

Suspected child physical abuse, ruled out

Excludes1: 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.-)

Z04.8 Encounter for examination and observation for other specified reasons

Encounter for examination and observation for request for expert evidence

Z04.9 Encounter for examination and observation for unspecified reason

Encounter for observation NOS

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm

Includes: medical surveillance following completed treatment

Use additional code to identify any acquired absence of organs (Z90.-)

Use additional code to identify the personal history of malignant neoplasm (Z85.-)

Excludes1: aftercare following medical care (Z43-Z49, Z51)

Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Includes: medical surveillance following completed treatment

Use additional code to identify any applicable history of disease code (Z86.-. Z87.-)

Excludes1: aftercare following medical care (Z43-Z49, Z51)

surveillance of contraception (Z30.4-)

surveillance of prosthetic and other medical devices (Z44-Z46)

Z11 Encounter for screening for infectious and parasitic diseases

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.

Excludes1: encounter for diagnostic examination-code to sign or symptom

Z11.0 Encounter for screening for intestinal infectious diseases

Z11.1 Encounter for screening for respiratory tuberculosis

Z11.2 Encounter for screening for other bacterial diseases

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Excludes2: encounter for screening for human immunodeficiency virus [HIV] (Z11.4)

encounter for screening for human papillomavirus (Z11.51)

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]

Z11.5 Encounter for screening for other viral diseases

Excludes2: encounter for screening for viral intestinal disease (Z11.0)

Z11.51 Encounter for screening for human papillomavirus (HPV)

Z11.59 Encounter for screening for other viral diseases

Z11.6 Encounter for screening for other protozoal diseases and helminthiases

Excludes2: encounter for screening for protozoal intestinal disease (Z11.0)

Z11.8 Encounter for screening for other infectious and parasitic diseases

Encounter for screening for chlamydia

Encounter for screening for rickettsial

Encounter for screening for spirochetal

Encounter for screening for mycoses

Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified

Z12 Encounter for screening for malignant neoplasms

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 to identify any family history of malignant neoplasm (Z80.-)

Excludes1: encounter for diagnostic examination-code to sign or symptom

Z12.0 Encounter for screening for malignant neoplasm of stomach

Z12.1 Encounter for screening for malignant neoplasm of intestinal tract

Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified

Z12.11 Encounter for screening for malignant neoplasm of colon

Z12.12 Encounter for screening for malignant neoplasm of rectum

Z12.13 Encounter for screening for malignant neoplasm of small intestine

Z12.2 Encounter for screening for malignant neoplasm of respiratory organs

Z12.3 Encounter for screening for malignant neoplasm of breast

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast

Excludes1: inconclusive mammogram (R92.2)

Z12.39 Encounter for other screening for malignant neoplasm of breast

Z12.4 Encounter for screening for malignant neoplasm of cervix

Encounter for screening pap smear for malignant neoplasm of cervix

Excludes1: encounter for screening for human papillomavirus (Z11.51)

when screening is part of general gynecological examination (Z01.4-)

Z12.5 Encounter for screening for malignant neoplasm of prostate

Z12.6 Encounter for screening for malignant neoplasm of bladder

Z12.7 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.71 Encounter for screening for malignant neoplasm of testis

Z12.72 Encounter for screening for malignant neoplasm of vagina

Vaginal pap smear status-post hysterectomy for non-malignant condition

Use additional code to identify acquired absence of uterus (Z90.71-)

Excludes1: vaginal pap smear status-post hysterectomy for malignant conditions (Z08)

Z12.73 Encounter for screening for malignant neoplasm of ovary

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.8 Encounter for screening for malignant neoplasm of other sites

Z12. 81 Encounter for screening for malignant neoplasm of oral cavity

Z12.82 Encounter for screening for malignant neoplasm of nervous system

Z12.83 Encounter for screening for malignant neoplasm of skin

Z12.89 Encounter for screening for malignant neoplasm of other sites

Z12.9 Encounter for screening for malignant neoplasm, site unspecified

Z13 Encounter for screening for other diseases and disorders

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.

Excludes1: encounter for diagnostic examination-code to sign or symptom

Z13.0 Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Z13.1 Encounter for screening for diabetes mellitus

Z13.2 Encounter for screening for nutritional, metabolic and other endocrine disorders

Z13.21 Encounter for screening for nutritional disorder

Z13.22 Encounter for screening for metabolic disorder

Z13.220 Encounter for screening for lipoid disorders

Encounter for screening for cholesterol level

Encounter for screening for hypercholesterolemia

Encounter for screening for hyperlipidemia

Z13.228 Encounter for screening for other metabolic disorders

Z13.29 Encounter for screening for other suspected endocrine disorder

Excludes1: encounter for screening for diabetes mellitus (Z13.1)

Z13.4 Encounter for screening for certain developmental disorders in childhood

Encounter for screening for developmental handicaps in early childhood

Excludes1: routine development testing of infant or child (Z00.1-)

Z13.5 Encounter for screening for eye and ear disorders

Excludes2: encounter for general hearing examination (Z01.1-)

encounter for general vision examination (Z01.0-)

Z13.6 Encounter for screening for cardiovascular disorders

Z13.7 Encounter for screening for genetic and chromosomal anomalies

Excludes1: genetic testing for procreative management (Z31.4-)

Z13. 71 Encounter for nonprocreative screening for genetic disease carrier status

Z13.79 Encounter for other screening for genetic and chromosomal anomalies

Z13.8 Encounter for screening for other specified diseases and disorders

Excludes2: screening for malignant neoplasms (Z12.-)

Z13.81 Encounter for screening for digestive system disorders

Z13.810 Encounter for screening for upper gastrointestinal disorder

Z13.811 Encounter for screening for lower gastrointestinal disorder

Excludes1: encounter for screening for intestinal infectious disease (Z11.0)

Z13.818 Encounter for screening for other digestive system disorders

Z13.82 Encounter for screening for musculoskeletal disorder

Z13.820 Encounter for screening for osteoporosis

Z13.828 Encounter for screening for other musculoskeletal disorder

Z13.83 Encounter for screening for respiratory disorder NEC

Excludes1: encounter for screening for respiratory tuberculosis (Z11.1)

Z13.84 Encounter for screening for dental disorders

Z13.85 Encounter for screening for nervous system disorders

Z13.850 Encounter for screening for traumatic brain injury

Z13.858 Encounter for screening for other nervous system disorders

Z13.88 Encounter for screening for disorder due to exposure to contaminants

Excludes1: those exposed to contaminants without suspected disorders (Z57-Z58)

Z13.89 Encounter for screening for other disorder

Encounter for screening for genitourinary disorders

Z13.9 Encounter for screening, unspecified

Genetic carrier and genetic susceptibility to disease (Z14-Z15)

Z14 Genetic carrier

Z14.0 Hemophilia A carrier

Z14. 01 Asymptomatic hemophilia A carrier

Z14.02 Symptomatic hemophilia A carrier

Z14.1 Cystic fibrosis carrier

Z14.8 Genetic carrier of other disease

Z15 Genetic susceptibility to disease

Includes: Confirmed abnormal gene

Use additional code, if applicable, for any associated family history of the disease (Z80-Z84)

Z15.0 Genetic susceptibility to malignant neoplasm

Code first, if applicable, any current malignant neoplasm (C00-C75, C81-C96)

Use additional code, if applicable, for any personal history of malignant neoplasm (Z85.-)

Z15.01 Genetic susceptibility to malignant neoplasm of breast

Z15.02 Genetic susceptibility to malignant neoplasm of ovary

Z15.03 Genetic susceptibility to malignant neoplasm of prostate

Z15.04 Genetic susceptibility to malignant neoplasm of endometrium

Z15.09 Genetic susceptibility to other malignant neoplasm

Z15.8 Genetic susceptibility to other disease

Z15.81 Genetic susceptibility to multiple endocrine neoplasia [MEN]

Z15.89 Genetic susceptibility to other disease

Infection with drug resistant microorganisms (Z16)

Z16 Infection with drug resistant microorganisms

This category is intended for use as an additional code for infectious conditions classified elsewhere to indicate the presence of drug-resistance of the infectious organism

Code first the infection

Estrogen receptor status (Z17)

Z17 Estrogen receptor status

Code first malignant neoplasm of breast (C50.-)

Z17.0 Estrogen receptor positive status [ER+]

Z17.1 Estrogen receptor negative status [ER-]

Persons with potential health hazards related to communicable diseases (Z20-Z28)

Z20 Contact with and (suspected) exposure to communicable diseases

Excludes1: carrier of infectious disease (Z22.-)

diagnosed current infectious or parasitic disease -see Alphabetic Index

Excludes2: personal history of infectious and parasitic diseases (Z86.1-)

Z20.0 Contact with and (suspected) exposure to intestinal infectious diseases

Z20.01 Contact with and (suspected) exposure to intestinal infectious diseases due to Escherichia coli (E. coli)

Z20.09 Contact with and (suspected) exposure to other intestinal infectious diseases

Z20.1 Contact with and (suspected) exposure to tuberculosis

Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission

Z20.3 Contact with and (suspected) exposure to rabies

Z20.4 Contact with and (suspected) exposure to rubella

Z20.5 Contact with and (suspected) exposure to viral hepatitis

Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]

Excludes1: asymptomatic human immunodeficiency virus [HIV]

HIV infection status (Z21)

Z20.7 Contact with and (suspected) exposure to pediculosis, acariasis and other infestations

Z20.8 Contact with and (suspected) exposure to other communicable diseases

Z20.81 Contact with and (suspected) exposure to other bacterial communicable diseases

Z20.810 Contact with and (suspected) exposure to anthrax

Z20.811 Contact with and (suspected) exposure to meningococcus

Z20.818 Contact with and (suspected) exposure to other bacterial communicable diseases

Z20.82 Contact with and (suspected) exposure to other viral communicable diseases

Z20.820 Contact with and (suspected) exposure to varicella

Z20.828 Contact with and (suspected) exposure to other viral communicable diseases

Z20.89 Contact with and (suspected) exposure to other communicable diseases

Z20. 9 Contact with and (suspected) exposure to unspecified communicable disease

Z21 Asymptomatic human immunodeficiency virus [HIV] infection status

Includes: HIV positive NOS

Code first: Human immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium, if applicable (O98.7-)

Excludes1: 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)

Z22 Carrier of infectious disease

Includes: colonization status

suspected carrier

Z22.0 Carrier of typhoid

Z22.1 Carrier of other intestinal infectious diseases

Z22.2 Carrier of diphtheria

Z22.3 Carrier of other specified bacterial diseases

Z22.31 Carrier of bacterial disease due to meningococci

Z22.32 Carrier of bacterial disease due to staphylococci

Z22.33 Carrier of bacterial disease due to streptococci

Z22.330 Carrier of Group B streptococcus

Z22.338 Carrier of other streptococcus

Z22.39 Carrier of other specified bacterial diseases

Z22.4 Carrier of infections with a predominantly sexual mode of transmission

Z22.5 Carrier of viral hepatitis

Z22.50 Carrier of unspecified viral hepatitis

Z22.51 Carrier of viral hepatitis B

Hepatitis B surface antigen [HBsAg] carrier

Z22.52 Carrier of viral hepatitis C

Z22.59 Carrier of other viral hepatitis

Z22.6 Carrier of human T-lymphotropic virus type-1 [HTLV-1] infection

Z22.8 Carrier of other infectious diseases

Z22.9 Carrier of infectious disease, unspecified

Z23 Encounter for immunization

Code first any routine childhood examination

Note: procedure codes are required to identify the types of immunizations given

Z28 Immunization not carried out and underimmunization status

Vaccination not carried out

Z28.0 Immunization not carried out because of contraindication

Z28.01 Immunization not carried out because of acute illness of patient

Z28.02 Immunization not carried out because of chronic illness or condition of patient

Z28.03 Immunization not carried out because of immune compromised state of patient

Z28.04 Immunization not carried out because of patient allergy to vaccine or component

Z28.09 Immunization not carried out because of other contraindication

Z28.1 Immunization not carried out because of patient decision for reasons of belief or group pressure

Immunization not carried out because of religious belief

Z28.2 Immunization not carried out because of patient decision for other and unspecified reason

Z28.20 Immunization not carried out because of patient decision for unspecified reason

Z28.21 Immunization not carried out because of patient refusal

Z28.29 Immunization not carried out because of patient decision for other reason

Z28.3 Underimmunization status

Delinquent immunization status

Lapsed immunization schedule status

Z28.8 Immunization not carried out for other reason

Z28.81 Immunization not carried out due to patient having had the disease

Z28.82 Immunization not carried out because of caregiver refusal

Immunization not carried out because of guardian refusal

Immunization not carried out because of parent refusal

Excludes2: immunization not carried out because of caregiver refusal because of religious belief (Z28.1)

Z28.89 Immunization not carried out for other reason

Z28.9 Immunization not carried out for unspecified reason

Persons encountering health services in circumstances related to reproduction (Z30-Z39)

Z30 Encounter for contraceptive management

Z30.0 Encounter for general counseling and advice on contraception

Z30.01 Encounter for initial prescription of contraceptives

Z30.011 Encounter for initial prescription of contraceptive pills

Z30.012 Encounter for prescription of emergency contraception

Encounter for postcoital contraception

Z30.013 Encounter for initial prescription of injectable contraceptive

Z30.014 Encounter for initial prescription of intrauterine contraceptive device

Z30.018 Encounter for initial prescription of other contraceptives

Z30.019 Encounter for initial prescription of contraceptives, unspecified

Z30.02 Counseling and instruction in natural family planning to avoid pregnancy

Z30.09 Encounter for other general counseling and advice on contraception

Encounter for family planning advice NOS

Z30.2 Encounter for sterilization

Z30.4 Encounter for surveillance of contraceptives

Z30.40 Encounter for surveillance of contraceptives, unspecified

Z30.41 Encounter for surveillance of contraceptive pills

Encounter for repeat prescription for contraceptive pill

Z30.42 Encounter for surveillance of injectable contraceptive

Z30.43 Encounter for surveillance of intrauterine contraceptive device

Encounter for checking, reinsertion or removal of intrauterine contraceptive device

Z30.49 Encounter for surveillance of other contraceptives

Z30.8 Encounter for other contraceptive management

Encounter for postvasectomy sperm count

Encounter for routine examination for contraceptive maintenance

Excludes1: sperm count following sterilization reversal (Z31.42)

sperm count for fertility testing (Z31.41)

Z30.9 Encounter for contraceptive management, unspecified

Z31 Encounter for procreative management

Excludes1: complications associated with artificial fertilization (N98.-)

female infertility (N97.-)

male infertility (N46.-)

Z31.0 Encounter for reversal of previous sterilization

Z31.4 Encounter for procreative investigation and testing

Excludes1: postvasectomy sperm count (Z30.8)

Z31.41 Encounter for fertility testing

Encounter for fallopian tube patency testing

Encounter for sperm count for fertility testing

Z31.42 Aftercare following sterilization reversal

Sperm count following sterilization reversal

Z31.43 Encounter for genetic testing of female for procreative management

Use additional code for habitual aborter, if applicable (N96, O26.2-)

Excludes1: nonprocreative genetic testing (Z13.7-)

Z31.430 Encounter of female for testing for genetic disease carrier status for procreative management

Z31.438 Encounter for other genetic testing of female for procreative managment

Z31.44 Encounter for genetic testing of male for procreative management

Excludes1: nonprocreative genetic testing (Z13.7-)

Z31.440 Encounter of male for testing for genetic disease carrier status for procreative management

Z31.441 Encounter for testing of male partner of habitual aborter

Z31.448 Encounter for other genetic testing of male for procreative management

Z31.49 Encounter for other procreative investigation and testing

Z31.5 Encounter for genetic counseling

Z31.6 Encounter for general counseling and advice on procreation

Z31.61 Procreative counseling and advice using natural family planning

Z31.62 Encounter for fertility preservation counseling

Encounter for fertility preservation counseling prior to cancer therapy

Encounter for fertility preservation counseling prior to surgical removal of gonads

Z31.69 Encounter for other general counseling and advice on procreation

Z31.8 Encounter for other procreative management

Z31.81 Encounter for male factor infertility in female patient

Z31.82 Encounter for Rh incompatibility status

Z31. 83 Encounter for assisted reproductive fertility procedure cycle

Patient undergoing in vitro fertilization cycle

Use additional code to identify the type of infertility

Excludes1: pre-cycle diagnosis and testing - code to reason for encounter

Z31.84 Encounter for fertility preservation procedure

Encounter for fertility preservation procedure prior to cancer therapy

Encounter for fertility preservation procedure prior to surgical removal of gonads

Z31.89 Encounter for other procreative management

Z31.9 Encounter for procreative management, unspecified

Z32 Encounter for pregnancy test and childbirth and childcare instruction

Z32.0 Encounter for pregnancy test

Z32.00 Encounter for pregnancy test, result unknown

Encounter for pregnancy test NOS

Z32.01 Encounter for pregnancy test, result positive

Z32.02 Encounter for pregnancy test, result negative

Z32.2 Encounter for childbirth instruction

Z32.3 Encounter for childcare instruction

Encounter for prenatal or postpartum childcare instruction

Z33 Pregnant state

Z33.1 Pregnant state, incidental

Pregnant state NOS

Excludes1: complications of pregnancy (O00-O99)

Z33.2 Encounter for elective termination of pregnancy

Excludes1: early fetal death with retention of dead fetus (O02.1)

late fetal death (O36.4)

spontaneous abortion (O03)

Z34 Encounter for supervision of normal pregnancy

Excludes1: any complication of pregnancy (O00-O99)

encounter for pregnancy test (Z32.0-)

encounter for supervision of high risk pregnancy (O09.-)

Z34.0 Encounter for supervision of normal first pregnancy

Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester

Z34.01 Encounter for supervision of normal first pregnancy, first trimester

Z34.02 Encounter for supervision of normal first pregnancy, second trimester

Z34.03 Encounter for supervision of normal first pregnancy, third trimester

Z34. 8 Encounter for supervision of other normal pregnancy

Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester

Z34.81 Encounter for supervision of other normal pregnancy, first trimester

Z34.82 Encounter for supervision of other normal pregnancy, second trimester

Z34.83 Encounter for supervision of other normal pregnancy, third trimester

Z34.9 Encounter for supervision of normal pregnancy, unspecified

Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester

Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester

Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester

Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester

Z36 Encounter for antenatal screening of mother

Excludes1: abnormal findings on antenatal screening of mother (O28.-)

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

Excludes2: genetic counseling and testing (Z31.43-, Z31.5)

routine prenatal care (Z34)

Z37 Outcome of delivery

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.

Excludes1: stillbirth (P95)

Z37.0 Single live birth

Z37.1 Single stillbirth

Z37.2 Twins, both liveborn

Z37.3 Twins, one liveborn and one stillborn

Z37.4 Twins, both stillborn

Z37.5 Other multiple births, all liveborn

Z37.50 Multiple births, unspecified, all liveborn

Z37.51 Triplets, all liveborn

Z37.52 Quadruplets, all liveborn

Z37.53 Quintuplets, all liveborn

Z37.54 Sextuplets, all liveborn

Z37.59 Other multiple births, all liveborn

Z37.6 Other multiple births, some liveborn

Z37.60 Multiple births, unspecified, some liveborn

Z37. 61 Triplets, some liveborn

Z37.62 Quadruplets, some liveborn

Z37.63 Quintuplets, some liveborn

Z37.64 Sextuplets, some liveborn

Z37.69 Other multiple births, some liveborn

Z37.7 Other multiple births, all stillborn

Z37.9 Outcome of delivery, unspecified

Multiple birth NOS

Single birth NOS

Z38 Liveborn infants according to place of birth and type of delivery

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.

Z38.0 Single liveborn infant, born in hospital

Single liveborn infant, born in birthing center or other health care facility

Z38.00 Single liveborn infant, delivered vaginally

Z38.01 Single liveborn infant, delivered by cesarean

Z38.1 Single liveborn infant, born outside hospital

Z38.2 Single liveborn infant, unspecified as to place of birth

Single liveborn infant NOS

Z38.3 Twin liveborn infant, born in hospital

Z38.30 Twin liveborn infant, delivered vaginally

Z38.31 Twin liveborn infant, delivered by cesarean

Z38.4 Twin liveborn infant, born outside hospital

Z38.5 Twin liveborn infant, unspecified as to place of birth

Z38.6 Other multiple liveborn infant, born in hospital

Z38.61 Triplet liveborn infant, delivered vaginally

Z38.62 Triplet liveborn infant, delivered by cesarean

Z38.63 Quadruplet liveborn infant, delivered vaginally

Z38.64 Quadruplet liveborn infant, delivered by cesarean

Z38.65 Quintuplet liveborn infant, delivered vaginally

Z38.66 Quintuplet liveborn infant, delivered by cesarean

Z38.68 Other multiple liveborn infant, delivered vaginally

Z38.69 Other multiple liveborn infant, delivered by cesarean

Z38.7 Other multiple liveborn infant, born outside hospital

Z38.8 Other multiple liveborn infant, unspecified as to place of birth

Z39 Encounter for maternal postpartum care and examination

Z39.0 Encounter for care and examination of mother immediately after delivery

Care and observation in uncomplicated cases when the delivery occurs outside a healthcare facility

Excludes1: care for postpartum complication- see Alphabetic index

Z39.1 Encounter for care and examination of lactating mother

Encounter for supervision of lactation

Excludes1: disorders of lactation (O92.-)

Z39.2 Encounter for routine postpartum follow-up

Encounters for other specific health care (Z40-Z53)

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

Excludes2: follow-up examination for medical surveillance after treatment (Z08-Z09)

Z40 Encounter for prophylactic surgery

Excludes1: organ donations (Z52.-)

therapeutic organ removal-code to condition

Z40.0 Encounter for prophylactic surgery for risk factors related to malignant neoplasms

Admission for prophylactic organ removal

Use additional code to identify risk factor

Z40.00 Encounter for prophylactic removal of unspecified organ

Z40.01 Encounter for prophylactic removal of breast

Z40.02 Encounter for prophylactic removal of ovary

Z40.09 Encounter for prophylactic removal of other organ

Z40.8 Encounter for other prophylactic surgery

Z40.9 Encounter for prophylactic surgery, unspecified

Z41 Encounter for procedures for purposes other than remedying health state

Z41.1 Encounter for cosmetic surgery

Encounter for cosmetic breast implant

Encounter for cosmetic procedure

Excludes1: encounter for breast reduction (N62)

encounter for plastic and reconstructive surgery following medical procedure or healed injury (Z42.-)

encounter for post-mastectomy breast implantation (Z42.1)

Z41.2 Encounter for routine and ritual male circumcision

Z41.3 Encounter for ear piercing

Z41.8 Encounter for other procedures for purposes other than remedying health state

Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified

Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury

Excludes1: encounter for cosmetic plastic surgery (Z41.1)

encounter for plastic surgery for treatment of current injury - code to relevent injury

Z42.1 Encounter for breast reconstruction following mastectomy

Excludes1: deformity and disproportion of reconstructed breast (N65.1-)

Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure or healed injury

Z43 Encounter for attention to artificial openings

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

Excludes1: artificial opening status only, without need for care (Z93.-)

complications of external stoma (J95.0-, K91.4-, K91.7-, N99.5-)

Excludes2: fitting and adjustment of prosthetic and other devices (Z44-Z46)

Z43.0 Encounter for attention to tracheostomy

Z43.1 Encounter for attention to gastrostomy

Z43.2 Encounter for attention to ileostomy

Z43.3 Encounter for attention to colostomy

Z43.4 Encounter for attention to other artificial openings of digestive tract

Z43.5 Encounter for attention to cystostomy

Z43.6 Encounter for attention to other artificial openings of urinary tract

Encounter for attention to nephrostomy

Encounter for attention to ureterostomy

Encounter for attention to urethrostomy

Z43.7 Encounter for attention to artificial vagina

Z43.8 Encounter for attention to other artificial openings

Z43.9 Encounter for attention to unspecified artificial opening

Z44 Encounter for fitting and adjustment of external prosthetic device

Includes: removal or replacement of external prosthetic device

Excludes1: malfunction or other complications of device - see Alphabetical Index

presence of prosthetic device (Z97.-)

Z44.0 Encounter for fitting and adjustment of artificial arm

Z44.00 Encounter for fitting and adjustment of unspecified artificial arm

Z44.001 Encounter for fitting and adjustment of unspecified right artificial arm

Z44.002 Encounter for fitting and adjustment of unspecified left artificial arm

Z44.009 Encounter for fitting and adjustment of unspecified artificial arm, unspecified arm

Z44. 01 Encounter for fitting and adjustment of complete artificial arm

Z44.011 Encounter for fitting and adjustment of complete right artificial arm

Z44.012 Encounter for fitting and adjustment of complete left artificial arm

Z44.019 Encounter for fitting and adjustment of complete artificial arm, unspecified arm

Z44.02 Encounter for fitting and adjustment of partial artificial arm

Z44.021 Encounter for fitting and adjustment of partial artificial right arm

Z44.022 Encounter for fitting and adjustment of partial artificial left arm

Z44.029 Encounter for fitting and adjustment of partial artificial arm, unspecified arm

Z44.1 Encounter for fitting and adjustment of artificial leg

Z44.10 Encounter for fitting and adjustment of unspecified artificial leg

Z44.101 Encounter for fitting and adjustment of unspecified right artificial leg

Z44.102 Encounter for fitting and adjustment of unspecified left artificial leg

Z44.109 Encounter for fitting and adjustment of unspecified artificial leg, unspecified leg

Z44.11 Encounter for fitting and adjustment of complete artificial leg

Z44.111 Encounter for fitting and adjustment of complete right artificial leg

Z44.112 Encounter for fitting and adjustment of complete left artificial leg

Z44.119 Encounter for fitting and adjustment of complete artificial leg, unspecified leg

Z44.12 Encounter for fitting and adjustment of partial artificial leg

Z44.121 Encounter for fitting and adjustment of partial artificial right leg

Z44.122 Encounter for fitting and adjustment of partial artificial left leg

Z44.129 Encounter for fitting and adjustment of partial artificial leg, unspecified leg

Z44.2 Encounter for fitting and adjustment of artificial eye

Excludes1: mechanical complication of ocular prosthesis (T85.3)

Z44.20 Encounter for fitting and adjustment of artificial eye, unspecified

Z44.21 Encounter for fitting and adjustment of artificial right eye

Z44. 22 Encounter for fitting and adjustment of artificial left eye

Z44.3 Encounter for fitting and adjustment of external breast prosthesis

Excludes1: 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)

Z44.30 Encounter for fitting and adjustment of external breast prosthesis, unspecified breast

Z44.31 Encounter for fitting and adjustment of external right breast prosthesis

Z44.32 Encounter for fitting and adjustment of external left breast prosthesis

Z44.8 Encounter for fitting and adjustment of other external prosthetic devices

Z44.9 Encounter for fitting and adjustment of unspecified external prosthetic device

Z45 Encounter for adjustment and management of implanted device

Includes: removal or replacement of implanted device

Excludes1: malfunction or other complications of device - see Alphabetical Index

Excludes2: encounter for fitting and adjustment of non-implanted device (Z46.-)

presence of prosthetic and other devices (Z95-Z97)

Z45.0 Encounter for adjustment and management of cardiac device

Z45.01 Encounter for adjustment and management of cardiac pacemaker

Z45.010 Encounter for checking and testing of cardiac pacemaker pulse generator [battery]

Encounter for replacing cardiac pacemaker pulse generator [battery]

Z45.018 Encounter for adjustment and management of other part of cardiac pacemaker

Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator

Z45.09 Encounter for adjustment and management of other cardiac device

Z45.1 Encounter for adjustment and management of infusion pump

Z45.2 Encounter for adjustment and management of vascular access device

Encounter for adjustment and management of vascular catheters

Excludes1: encounter for adjustment and management of renal dialysis catheter (Z49.01)

Z45.3 Encounter for adjustment and management of implanted devices of the special senses

Z45.31 Encounter for adjustment and management of implanted visual substitution device

Z45.32 Encounter for adjustment and management of implanted hearing device

Excludes1: Encounter for fitting and adjustment of hearing aide (Z46.1)

Z45.320 Encounter for adjustment and management of bone conduction device

Z45.321 Encounter for adjustment and management of cochlear device

Z45.328 Encounter for adjustment and management of other implanted hearing device

Z45.4 Encounter for adjustment and management of implanted nervous system device

Z45.41 Encounter for adjustment and management of cerebrospinal fluid drainage device

Encounter for adjustment and management of cerebral ventricular (communicating) shunt

Z45.42 Encounter for adjustment and management of neuropacemaker (brain) (peripheral nerve) (spinal cord)

Z45.49 Encounter for adjustment and management of other implanted nervous system device

Z45.8 Encounter for adjustment and management of other implanted devices

Z45.81 Encounter for adjustment or removal of breast implant

Encounter for elective implant exchange (different material) (different size)

Encounter removal of tissue expander without synchronous insertion of permanent implant

Excludes1: 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)

Z45.811 Encounter for adjustment or removal of right breast implant

Z45.812 Encounter for adjustment or removal of left breast implant

Z45. 819 Encounter for adjustment or removal of unspecified breast implant

Z45.82 Encounter for adjustment or removal of myringotomy device (stent) (tube)

Z45.89 Encounter for adjustment and management of other implanted devices

Z45.9 Encounter for adjustment and management of unspecified implanted device

Z46 Encounter for fitting and adjustment of other devices

Includes: removal or replacement of other device

Excludes1: malfunction or other complications of device - see Alphabetical Index

Excludes2: encounter for fitting and management of implanted devices (Z45.-)

issue of repeat prescription only (Z76.0)

presence of prosthetic and other devices (Z95-Z97)

Z46.0 Encounter for fitting and adjustment of spectacles and contact lenses

Z46.1 Encounter for fitting and adjustment of hearing aid

Excludes1: encounter for adjustment and management of implanted hearing device (Z45.32-)

Z46.2 Encounter for fitting and adjustment of other devices related to nervous system and special senses

Excludes2: encounter for adjustment and management of implanted nervous system device (Z45.4-)

encounter for adjustment and management of implanted visual substitution device (Z45.31)

Z46.3 Encounter for fitting and adjustment of dental prosthetic device

Encounter for fitting and adjustment of dentures

Z46.4 Encounter for fitting and adjustment of orthodontic device

Z46.5 Encounter for fitting and adjustment of other gastrointestinal appliance and device

Excludes1: encounter for attention to artificial openings of digestive tract (Z43.1-Z43.4)

Z46.51 Encounter for fitting and adjustment of gastric lap band

Z46.59 Encounter for fitting and adjustment of other gastrointestinal appliance and device

Z46.6 Encounter for fitting and adjustment of urinary device

Excludes2: attention to artificial openings of urinary tract (Z43.5, Z43.6)

Z46.8 Encounter for fitting and adjustment of other specified devices

Z46.81 Encounter for fitting and adjustment of insulin pump

Encounter for insulin pump titration

Encounter for insulin pump instruction and training

Z46.82 Encounter for fitting and adjustment of non-vascular catheter

Z46. 89 Encounter for fitting and adjustment of other specified devices

Encounter for fitting and adjustment of wheelchair

Z46.9 Encounter for fitting and adjustment of unspecified device

Z47 Orthopedic aftercare

Excludes1 aftercare for healing fracture-code to fracture with 7th character D

Z47.1 Aftercare following joint replacement surgery

Use additional code to identify the joint (Z96.6-)

Z47.2 Encounter for removal of internal fixation device

Excludes1: 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-)

Z47.8 Encounter for other orthopedic aftercare

Z47.81 Encounter for orthopedic aftercare following surgical amputation

Use additional code to identify the limb amputated (Z89.-)

Z47.82 Encounter for orthopedic aftercare following scoliosis surgery

Z47.89 Encounter for other orthopedic aftercare

Z48 Encounter for other postprocedural aftercare

Excludes1: encounter for follow-up examination after completed treatment (Z08-Z09)

Excludes2: encounter for attention to artificial openings (Z43.-)

encounter for fitting and adjustment of prosthetic and other devices (Z44-Z46)

Z48.0 Encounter for attention to dressings, sutures and drains

Excludes1: encounter for planned postprocedural wound closure (Z48.1)

Z48.00 Encounter for change or removal of nonsurgical wound dressing

Encounter for change or removal of wound dressing NOS

Z48.01 Encounter for change or removal of surgical wound dressing

Z48.02 Encounter for removal of sutures

Encounter for removal of staples

Z48.03 Encounter for change or removal of drains

Z48.1 Encounter for planned postprocedural wound closure

Excludes1: encounter for attention to dressings and sutures (Z48.0-)

Z48.2 Encounter for aftercare following organ transplant

Z48.21 Encounter for aftercare following heart transplant

Z48.22 Encounter for aftercare following kidney transplant

Z48.23 Encounter for aftercare following liver transplant

Z48.24 Encounter for aftercare following lung transplant

Z48.28 Encounter for aftercare following multiple organ transplant

Z48.280 Encounter for aftercare following heart-lung transplant

Z48.288 Encounter for aftercare following multiple organ transplant

Z48.29 Encounter for aftercare following other organ transplant

Z48.290 Encounter for aftercare following bone marrow transplant

Z48.298 Encounter for aftercare following other organ transplant

Z48.3 Aftercare following surgery for neoplasm

Use additional code to identify the neoplasm

Z48.8 Encounter for other specified postprocedural aftercare

Z48.81 Encounter for surgical aftercare following surgery on specified body systems

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.

Excludes1: aftercare for injury- code the injury with 7th character D

Excludes2: aftercare following organ transplant (Z48.2-)

aftercare following surgery for neoplasm (Z48.3)

orthopedic aftercare (Z47.-)

Z48.810 Encounter for surgical aftercare following surgery on the sense organs

Z48.811 Encounter for surgical aftercare following surgery on the nervous system

Excludes2: encounter for surgical aftercare following surgery on the sense organs (Z48.810)

Z48.812 Encounter for surgical aftercare following surgery on the circulatory system

Z48.813 Encounter for surgical aftercare following surgery on the respiratory system

Z48.814 Encounter for surgical aftercare following surgery on the teeth or oral cavity

Z48. 815 Encounter for surgical aftercare following surgery on the digestive system

Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system

Excludes1: encounter for aftercare following sterilization reversal (Z31.42)

Z48.817 Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue

Z48.89 Encounter for other specified surgical aftercare

Z49 Encounter for care involving renal dialysis

Code also associated end stage renal disease (N18.6)

Z49.0 Preparatory care for renal dialysis

Encounter for dialysis instruction and training

Z49.01 Encounter for fitting and adjustment of extracorporeal dialysis catheter

Removal or replacement of renal dialysis catheter

Toilet or cleansing of renal dialysis catheter

Z49.02 Encounter for fitting and adjustment of peritoneal dialysis catheter

Z49.3 Encounter for adequacy testing for dialysis

Z49.31 Encounter for adequacy testing for hemodialysis

Z49.32 Encounter for adequacy testing for peritoneal dialysis

Encounter for peritoneal equilibration test

Z51 Encounter for other aftercare

Code also condition requiring care

Excludes1: follow-up examination after treatment (Z08-Z09)

Z51.0 Encounter for antineoplastic radiation therapy

Z51.1 Encounter for antineoplastic chemotherapy and immunotherapy

Excludes2: encounter for chemotherapy and immunotherapy for nonneoplastic condition - code to condition

Z51.11 Encounter for antineoplastic chemotherapy

Z51.12 Encounter for antineoplastic immunotherapy

Z51.5 Encounter for palliative care

Z51.8 Encounter for other specified aftercare

Excludes1: holiday relief care (Z75.5)

Z51.81 Encounter for therapeutic drug level monitoring

Code also any long-term (current) drug therapy (Z79.-)

Excludes1: encounter for blood-drug test for administrative or medicolegal reasons (Z02.83)

Z51.89 Encounter for other specified aftercare

Z52 Donors of organs and tissues

Includes: autologous and other living donors

Excludes1: cadaveric donor - omit code

examination of potential donor (Z00.5)

Z52.0 Blood donor

Z52.00 Unspecified blood donor

Z52.000 Unspecified donor, whole blood

Z52.001 Unspecified donor, stem cells

Z52.008 Unspecified donor, other blood

Z52.01 Autologous blood donor

Z52.010 Autologous donor, whole blood

Z52.011 Autologous donor, stem cells

Z52.018 Autologous donor, other blood

Z52.09 Other blood donor

Volunteer donor

Z52.090 Other blood donor, whole blood

Z52.091 Other blood donor, stem cells

Z52.098 Other blood donor, other blood

Z52.1 Skin donor

Z52.10 Skin donor, unspecified

Z52.11 Skin donor, autologous

Z52.19 Skin donor, other

Z52.2 Bone donor

Z52.20 Bone donor, unspecified

Z52.21 Bone donor, autologous

Z52.29 Bone donor, other

Z52.3 Bone marrow donor

Z52.4 Kidney donor

Z52.5 Cornea donor

Z52.6 Liver donor

Z52.8 Donor of other specified organs or tissues

Z52.81 Egg (Oocyte) donor

Z52.810 Egg (Oocyte) donor under age 35, anonymous recipient

Egg donor under age 35 NOS

Z52.811 Egg (Oocyte) donor under age 35, designated recipient

Z52.812 Egg (Oocyte) donor age 35 and over, anonymous recipient

Egg donor age 35 and over NOS

Z52.813 Egg (Oocyte) donor age 35 and over, designated recipient

Z52.819 Egg (Oocyte) donor, unspecified

Z52.89 Donor of other specified organs or tissues

Z52.9 Donor of unspecified organ or tissue

Donor NOS

Z53 Persons encountering health services for specific procedures and treatment, not carried out

Z53. 0 Procedure and treatment not carried out because of contraindication

Z53.01 Procedure and treatment not carried out due to patient smoking

Z53.09 Procedure and treatment not carried out because of other contraindication

Z53.1 Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure

Z53.2 Procedure and treatment not carried out because of patient's decision for other and unspecified reasons

Z53.20 Procedure and treatment not carried out because of patient's decision for unspecified reasons

Z53.21 Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider

Z53.29 Procedure and treatment not carried out because of patient's decision for other reasons

Z53.8 Procedure and treatment not carried out for other reasons

Z53.9 Procedure and treatment not carried out, unspecified reason

Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65)

Z55 Problems related to education and literacy

Excludes1: disorders of psychological development (F80-F89)

Z55.0 Illiteracy and low-level literacy

Z55.1 Schooling unavailable and unattainable

Z55.2 Failed school examinations

Z55.3 Underachievement in school

Z55.4 Educational maladjustment and discord with teachers and classmates

Z55.8 Other problems related to education and literacy

Problems related to inadequate teaching

Z55.9 Problems related to education and literacy, unspecified

Academic problems NOS

Z56 Problems related to employment and unemployment

Excludes2: occupational exposure to risk factors (Z57.-)

problems related to housing and economic circumstances (Z59.-)

Z56.0 Unemployment, unspecified

Z56.1 Change of job

Z56.2 Threat of job loss

Z56.3 Stressful work schedule

Z56.4 Discord with boss and workmates

Z56.5 Uncongenial work environment

Difficult conditions at work

Z56.6 Other physical and mental strain related to work

Z56.8 Other problems related to employment

Z56.81 Sexual harassment on the job

Z56.82 Military deployment status

Individual (civilian or military) currently deployed in theater or in support of military war, peacekeeping and humanitarian operations

Z56.89 Other problems related to employment

Z56.9 Unspecified problems related to employment

Occupational problems NOS

Z57 Occupational exposure to risk factors

Z57.0 Occupational exposure to noise

Z57.1 Occupational exposure to radiation

Z57.2 Occupational exposure to dust

Z57.3 Occupational exposure to other air contaminants

Z57.31 Occupational exposure to environmental tobacco smoke

Excludes2: exposure to environmental tobacco smoke (Z77.22)

Z57.39 Occupational exposure to other air contaminants

Z57.4 Occupational exposure to toxic agents in agriculture

Occupational exposure to solids, liquids, gases or vapors in agriculture

Z57.5 Occupational exposure to toxic agents in other industries

Occupational exposure to solids, liquids, gases or vapors in other industries

Z57.6 Occupational exposure to extreme temperature

Z57.7 Occupational exposure to vibration

Z57.8 Occupational exposure to other risk factors

Z57.9 Occupational exposure to unspecified risk factor

Z59 Problems related to housing and economic circumstances

Excludes2: problems related to upbringing (Z62.-)

Z59.0 Homelessness

Z59.1 Inadequate housing

Lack of heating

Restriction of space

Technical defects in home preventing adequate care

Unsatisfactory surroundings

Excludes1: problems related to the natural and physical environment (Z77.1-)

Z59.2 Discord with neighbors, lodgers and landlord

Z59.3 Problems related to living in residential institution

Boarding-school resident

Excludes1: institutional upbringing (Z62.2)

Z59.4 Lack of adequate food and safe drinking water

Inadequate drinking water supply

Excludes1: effects of hunger (T73.0)

inappropriate diet or eating habits (Z72.4)

malnutrition (E40-E46)

Z59.5 Extreme poverty

Z59.6 Low income

Z59.7 Insufficient social insurance and welfare support

Z59.8 Other problems related to housing and economic circumstances

Foreclosure on loan

Isolated dwelling

Problems with creditors

Z59.9 Problem related to housing and economic circumstances, unspecified

Z60 Problems related to social environment

Z60.0 Problems of adjustment to life-cycle transitions

Empty nest syndrome

Phase of life problem

Problem with adjustment to retirement [pension]

Z60.2 Problems related to living alone

Z60.3 Acculturation difficulty

Problem with migration

Problem with social transplantation

Z60.4 Social exclusion and rejection

Exclusion and rejection on the basis of personal characteristics, such as unusual physical appearance, illness or behavior.

Excludes1: target of adverse discrimination such as for racial or religious reasons (Z60.5)

Z60.5 Target of (perceived) adverse discrimination and persecution

Excludes1: social exclusion and rejection (Z60.4)

Z60.8 Other problems related to social environment

Z60.9 Problem related to social environment, unspecified

Z62 Problems related to upbringing

Current and past negative life events in childhood

Current and past problems of a child related to upbringing

Excludes2: maltreatment syndrome (T74.-)

problems related to housing and economic circumstances (Z59.-)

Z62.0 Inadequate parental supervision and control

Z62.1 Parental overprotection

Z62.2 Upbringing away from parents

Excludes1: problems with boarding school (Z59.3)

Z62.21 Child in welfare custody

Child in care of non-parental family member

Child in foster care

Excludes2: problem for parent due to child in welfare custody (Z63.5)

Z62.22 Institutional upbringing

Child living in orphanage or group home

Z62.29 Other upbringing away from parents

Z62.3 Hostility towards and scapegoating of child

Z62.6 Inappropriate (excessive) parental pressure

Z62.8 Other specified problems related to upbringing

Z62.81 Personal history of abuse in childhood

Z62.810 Personal history of physical and sexual abuse in childhood

Excludes1: current child physical abuse (T74.12, T76.12)

current child sexual abuse (T74. 12, T76.12)

Z62.811 Personal history of psychological abuse in childhood

Excludes1: current child psychological abuse (T74.32, T76.32)

Z62.812 Personal history of neglect in childhood

Excludes1: current child neglect (T74.02, T76.02)

Z62.819 Personal history of unspecified abuse in childhood

Excludes1: current child abuse NOS (T74.92, T76.92)

Z62.82 Parent-child conflict

Z62.820 Parent-biological child conflict

Parent-child problem NOS

Z62.821 Parent-adopted child conflict

Z62.822 Parent-foster child conflict

Z62.89 Other specified problems related to upbringing

Z62.890 Parent-child estrangement NEC

Z62.891 Sibling rivalry

Z62.898 Other specified problems related to upbringing

Z62.9 Problem related to upbringing, unspecified

Z63 Other problems related to primary support group, including family circumstances

Excludes2: maltreatment syndrome (T74.-, T76)

parent-child problems (Z62.-)

problems related to negative life events in childhood (Z62.-)

problems related to upbringing (Z62.-)

Z63.0 Problems in relationship with spouse or partner

Excludes1: counseling for spousal or partner abuse problems (Z69.1)

counseling related to sexual attitude, behavior, and orientation (Z70.-)

Z63.1 Problems in relationship with in-laws

Z63.3 Absence of family member

Excludes1: absence of family member due to disappearance and death (Z63.4)

absence of family member due to separation and divorce (Z63.5)

Z63.31 Absence of family member due to military deployment

Individual or family affected by other family member being on military deployment

Excludes1: family disruption due to return of family member from military deployment (Z63.71)

Z63.32 Other absence of family member

Z63.4 Disappearance and death of family member

Assumed death of family member

Bereavement

Z63.5 Disruption of family by separation and divorce

Marital estrangement

Z63.6 Dependent relative needing care at home

Z63.7 Other stressful life events affecting family and household

Z63.71 Stress on family due to return of family member from military deployment

Individual or family affected by family member having returned from military deployment (current or past conflict)

Z63.72 Alcoholism and drug addiction in family

Z63.79 Other stressful life events affecting family and household

Anxiety (normal) about sick person in family

Health problems within family

Ill or disturbed family member

Isolated family

Z63.8 Other specified problems related to primary support group

Family discord NOS

Family estrangement NOS

High expressed emotional level within family

Inadequate family support NOS

Inadequate or distorted communication within family

Z63.9 Problem related to primary support group, unspecified

Relationship disorder NOS

Z64 Problems related to certain psychosocial circumstances

Z64.0 Problems related to unwanted pregnancy

Z64.1 Problems related to multiparity

Z64.4 Discord with counselors

Discord with probation officer

Discord with social worker

Z65 Problems related to other psychosocial circumstances

Z65.0 Conviction in civil and criminal proceedings without imprisonment

Z65.1 Imprisonment and other incarceration

Z65.2 Problems related to release from prison

Z65.3 Problems related to other legal circumstances

Arrest

Child custody or support proceedings

Litigation

Prosecution

Z65.4 Victim of crime and terrorism

Victim of torture

Z65.5 Exposure to disaster, war and other hostilities

Excludes1: target of perceived discrimination or persecution (Z60.5)

Z65.8 Other specified problems related to psychosocial circumstances

Z65.9 Problem related to unspecified psychosocial circumstances

Do not resuscitate status (Z66)

Z66 Do not resuscitate

Includes: DNR status

Blood type (Z67)

Z67 Blood type

Z67.1 Type A blood

Z67.10 Type A blood, Rh positive

Z67.11 Type A blood, Rh negative

Z67.2 Type B blood

Z67.20 Type B blood, Rh positive

Z67.21 Type B blood, Rh negative

Z67.3 Type AB blood

Z67.30 Type AB blood, Rh positive

Z67.31 Type AB blood, Rh negative

Z67.4 Type O blood

Z67.40 Type O blood, Rh positive

Z67.41 Type O blood, Rh negative

Z67.9 Unspecified blood type

Z67.90 Unspecified blood type, Rh positive

Z67.91 Unspecified blood type, Rh negative

Body mass index (BMI) (Z68)

Z68 Body mass index (BMI)

Kilograms per meters squared

Note: BMI adult codes are for use for persons 21 years of age or older

BMI pediatric codes are for use for persons 2-20 years of age. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC)

Z68.1 Body mass index (BMI) 19 or less, adult

Z68.2 Body mass index (BMI) 20-29, adult

Z68.20 Body mass index (BMI) 20.0-20.9, adult

Z68.21 Body mass index (BMI) 21.0-21.9, adult

Z68.22 Body mass index (BMI) 22.0-22.9, adult

Z68.23 Body mass index (BMI) 23.0-23.9, adult

Z68.24 Body mass index (BMI) 24.0-24.9, adult

Z68.25 Body mass index (BMI) 25.0-25.9, adult

Z68.26 Body mass index (BMI) 26.0-26.9, adult

Z68.27 Body mass index (BMI) 27.0-27.9, adult

Z68.28 Body mass index (BMI) 28.0-28.9, adult

Z68.29 Body mass index (BMI) 29.0-29.9, adult

Z68.3 Body mass index (BMI) 30-39, adult

Z68.30 Body mass index (BMI) 30.0-30.9, adult

Z68.31 Body mass index (BMI) 31.0-31.9, adult

Z68.32 Body mass index (BMI) 32.0-32.9, adult

Z68.33 Body mass index (BMI) 33.0-33.9, adult

Z68.34 Body mass index (BMI) 34.0-34.9, adult

Z68.35 Body mass index (BMI) 35.0-35.9, adult

Z68.36 Body mass index (BMI) 36.0-36.9, adult

Z68.37 Body mass index (BMI) 37.0-37.9, adult

Z68.38 Body mass index (BMI) 38.0-38.9, adult

Z68.39 Body mass index (BMI) 39.0-39.9, adult

Z68.4 Body mass index (BMI) 40 or greater, adult

Z68.5 Body mass index (BMI) pediatric

Z68.51 Body mass index (BMI) pediatric, less than 5th percentile for age

Z68.52 Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age

Z68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age

Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age

Persons encountering health services in other circumstances (Z69-Z76)

Z69 Encounter for mental health services for victim and perpetrator of abuse

Counseling for victims and perpetrators of abuse

Z69.0 Encounter for mental health services for child abuse problems

Z69.01 Encounter for mental health services for parental child abuse

Z69.010 Encounter for mental health services for victim of parental child abuse

Z69.011 Encounter for mental health services for perpetrator of parental child abuse

Excludes1: encounter for mental health services for non-parental child abuse (Z69.02-)

Z69.02 Encounter for mental health services for non-parental child abuse

Z69.020 Encounter for mental health services for victim of non-parental child abuse

Z69.021 Encounter for mental health services for perpetrator of non-parental child abuse

Z69.1 Encounter for mental health services for spousal or partner abuse problems

Z69.11 Encounter for mental health services for victim of spousal or partner abuse

Z69.12 Encounter for mental health services for perpetrator of spousal or partner abuse

Z69.8 Encounter for mental health services for victim or perpetrator of other abuse

Z69.81 Encounter for mental health services for victim of other abuse

Encounter for rape victim counseling

Z69.82 Encounter for mental health services for perpetrator of other abuse

Z70 Counseling related to sexual attitude, behavior and orientation

Encounter for mental health services for sexual attitude, behavior and orientation

Excludes2: contraceptive or procreative counseling (Z30-Z31)

Z70.0 Counseling related to sexual attitude

Z70.1 Counseling related to patient's sexual behavior and orientation

Patient concerned regarding impotence

Patient concerned regarding non-responsiveness

Patient concerned regarding promiscuity

Patient concerned regarding sexual orientation

Z70.2 Counseling related to sexual behavior and orientation of third party

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

Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation

Z70.8 Other sex counseling

Encounter for sex education

Z70.9 Sex counseling, unspecified

Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified

Excludes2: contraceptive or procreation counseling (Z30-Z31)

sex counseling (Z70.-)

Z71.0 Person encountering health services to consult on behalf of another person

Person encountering health services to seek advice or treatment for non-attending third party

Excludes2: anxiety (normal) about sick person in family (Z63.7)

expectant (adoptive) parent(s) pre-birth pediatrician visit (Z76.81)

Z71.1 Person with feared health complaint in whom no diagnosis is made

Person encountering health services with feared condition which was not demonstrated

Person encountering health services in which problem was normal state

"Worried well"

Excludes1: medical observation for suspected diseases and conditions proven not to exist (Z03.-)

Z71.2 Person consulting for explanation of examination or test findings

Z71.3 Dietary counseling and surveillance

Use additional code for any associated underlying medical condition

Use additional code to identify body mass index (BMI), if known (Z68.-)

Z71.4 Alcohol abuse counseling and surveillance

Use additional code for alcohol abuse or dependence (F10.-)

Z71.41 Alcohol abuse counseling and surveillance of alcoholic

Z71.42 Counseling for family member of alcoholic

Counseling for significant other, partner, or friend of alcoholic

Z71.5 Drug abuse counseling and surveillance

Use additional code for drug abuse or dependence (F11-F16, F18-F19)

Z71.51 Drug abuse counseling and surveillance of drug abuser

Z71. 52 Counseling for family member of drug abuser

Counseling for significant other, partner, or friend of drug abuser

Z71.6 Tobacco abuse counseling

Use additional code for nicotine dependence (F17.-)

Z71.7 Human immunodeficiency virus [HIV] counseling

Z71.8 Other specified counseling

Excludes2: counseling for contraception (Z30.0-)

counseling for genetics (Z31.5)

counseling for procreative management (Z31.6-)

Z71.81 Spiritual or religious counseling

Z71.89 Other specified counseling

Z71.9 Counseling, unspecified

Encounter for medical advice NOS

Z72 Problems related to lifestyle

Excludes2: problems related to life-management difficulty (Z73.-)

problems related to socioeconomic and psychosocial circumstances (Z55-Z65)

Z72.0 Tobacco use

Tobacco use NOS

Excludes1: history of tobacco dependence (Z87.891)

nicotine dependence (F17.2-)

tobacco dependence (F17.2-)

tobacco use during pregnancy (O99.33-)

Z72.3 Lack of physical exercise

Z72.4 Inappropriate diet and eating habits

Excludes1: 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)

Z72.5 High risk sexual behavior

Promiscuity

Excludes1: paraphilias (F65)

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z72.6 Gambling and betting

Excludes1: compulsive or pathological gambling (F63.0)

Z72.8 Other problems related to lifestyle

Z72.81 Antisocial behavior

Excludes1: conduct disorders (F91.-)

Z72.810 Child and adolescent antisocial behavior

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

Z72.811 Adult antisocial behavior

Adult antisocial behavior without manifest psychiatric disorder

Z72.82 Problems related to sleep

Z72.820 Sleep deprivation

Lack of adequate sleep

Excludes1: insomnia (G47.0-)

Z72.821 Inadequate sleep hygiene

Bad sleep habits

Irregular sleep habits

Unhealthy sleep wake schedule

Excludes1: insomnia (F51.0-, G47.0-)

Z72.89 Other problems related to lifestyle

Self-damaging behavior

Z72.9 Problem related to lifestyle, unspecified

Z73 Problems related to life management difficulty

Excludes2: problems related to socioeconomic and psychosocial circumstances (Z55-Z65)

Z73.0 Burn-out

Z73.1 Type A behavior pattern

Z73.2 Lack of relaxation and leisure

Z73.3 Stress, not elsewhere classified

Physical and mental strain NOS

Excludes1: stress related to employment or unemployment (Z56.-)

Z73.4 Inadequate social skills, not elsewhere classified

Z73.5 Social role conflict, not elsewhere classified

Z73.6 Limitation of activities due to disability

Excludes1: care-provider dependency (Z74.-)

Z73.8 Other problems related to life management difficulty

Z73.81 Behavioral insomnia of childhood

Z73.810 Behavioral insomnia of childhood, sleep-onset association type

Z73.811 Behavioral insomnia of childhood, limit setting type

Z73.812 Behavioral insomnia of childhood, combined type

Z73.819 Behavioral insomnia of childhood, unspecified type

Z73.82 Dual sensory impairment

Z73.89 Other problems related to life management difficulty

Z73.9 Problem related to life management difficulty, unspecified

Z74 Problems related to care provider dependency

Excludes2: dependence on enabling machines or devices NEC (Z99.-)

Z74.0 Reduced mobility

Z74.01 Bed confinement status

Bedridden

Z74.09 Other reduced mobility

Chairridden

Reduced mobility NOS

Excludes2: wheelchair dependence (Z99.3)

Z74.1 Need for assistance with personal care

Z74.2 Need for assistance at home and no other household member able to render care

Z74.3 Need for continuous supervision

Z74.8 Other problems related to care provider dependency

Z74.9 Problem related to care provider dependency, unspecified

Z75 Problems related to medical facilities and other health care

Z75.0 Medical services not available in home

Excludes1: no other household member able to render care (Z74.2)

Z75.1 Person awaiting admission to adequate facility elsewhere

Z75.2 Other waiting period for investigation and treatment

Z75.3 Unavailability and inaccessibility of health-care facilities

Excludes1: bed unavailable (Z75.1)

Z75.4 Unavailability and inaccessibility of other helping agencies

Z75.5 Holiday relief care

Z75.8 Other problems related to medical facilities and other health care

Z75.9 Unspecified problem related to medical facilities and other health care

Z76 Persons encountering health services in other circumstances

Z76.0 Encounter for issue of repeat prescription

Encounter for issue of repeat prescription for appliance

Encounter for issue of repeat prescription for medicaments

Encounter for issue of repeat prescription for spectacles

Excludes2: issue of medical certificate (Z02.7)

repeat prescription for contraceptive (Z30.4-)

Z76.1 Encounter for health supervision and care of foundling

Z76.2 Encounter for health supervision and care of other healthy infant and child

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

Z76.3 Healthy person accompanying sick person

Z76.4 Other boarder to healthcare facility

Excludes1: homelessness (Z59.0)

Z76.5 Malingerer [conscious simulation]

Person feigning illness (with obvious motivation)

Excludes1: factitious disorder (F68.1-)

peregrinating patient (F68.1-)

Z76.8 Persons encountering health services in other specified circumstances

Z76.81 Expectant parent(s) prebirth pediatrician visit

Pre-adoption pediatrician visit for adoptive parent(s)

Z76.82 Awaiting organ transplant status

Patient waiting for organ availability

Z76.89 Persons encountering health services in other specified circumstances

Persons encountering health services NOS

Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)

Code also any follow-up examination (Z08-Z09)

Z77 Other contact with and (suspected) exposures hazardous to health

Includes: contact with and (suspected) exposures to potential hazards to health

Excludes2: contact with and (suspected) exposure to communicable diseases (Z20.-)

exposure to (parental) (environmental) tobacco smoke in the perinatal period (P96.81)

newborn (suspected to be) affected by noxious substances transmitted via placenta or breast milk (P04.-)

occupational exposure to risk factors (Z57.-)

toxic effects of substances chiefly nonmedicinal as to source (T51-T65)

Z77.0 Contact with and (suspected) exposure to hazardous, chiefly nonmedicinal, chemicals

Z77.01 Contact with and (suspected) exposure to hazardous metals

Z77.010 Contact with and (suspected) exposure to arsenic

Z77.011 Contact with and (suspected) exposure to lead

Z77. 018 Contact with and (suspected) exposure to other hazardous metals

Contact with and (suspected) exposure to chromium compounds

Contact with and (suspected) exposure to nickel dust

Z77.02 Contact with and (suspected) exposure to hazardous aromatic compounds

Z77.020 Contact with and (suspected) exposure to aromatic amines

Z77.021 Contact with and (suspected) exposure to benzene

Z77.028 Contact with and (suspected) exposure to other hazardous aromatic compounds

Aromatic dyes NOS

Polycyclic aromatic hydrocarbons

Z77.09 Contact with and (suspected) exposure to other hazardous, chiefly nonmedicinal, chemicals

Z77.090 Contact with and (suspected) exposure to asbestos

Z77.098 Contact with and (suspected) exposure to other hazardous, chiefly nonmedicinal, chemicals

Dyes NOS

Z77.1 Contact with and (suspected) exposure to environmental pollution and hazards in the physical environment

Z77.11 Contact with and (suspected) exposure to environmental pollution

Z77.110 Contact with and (suspected) exposure to air pollution

Z77.111 Contact with and (suspected) exposure to water pollution

Z77.112 Contact with and (suspected) exposure to soil pollution

Z77.118 Contact with and (suspected) exposure to other environmental pollution

Z77.12 Contact with and (suspected) exposure to hazards in the physical environment

Z77.120 Contact with and (suspected) exposure to mold (toxic)

Z77.121 Contact with and (suspected) exposure to harmful algae and algae toxins

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

Z77.122 Contact with and (suspected) exposure to noise

Z77.123 Contact with and (suspected) exposure to radon and other naturally occuring radiation

Excludes2: radiation exposure as the cause of a confirmed condition (W88-W90, X39.0-)

radiation sickness NOS (T66)

Z77.128 Contact with and (suspected) exposure to other hazards in the physical environment

Z77.2 Contact with and (suspected ) exposure to other hazardous substances

Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids

Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)

Exposure to second hand tobacco smoke (acute) (chronic)

Passive smoking (acute) (chronic)

Excludes1: nicotine dependence (F17.-)

tobacco use (Z72.0)

Excludes2: occupational exposure to environmental tobacco smoke (Z57.31)

Z77.29 Contact with and (suspected ) exposure to other hazardous substances

Z77.9 Other contact with and (suspected) exposures hazardous to health

Z78 Other specified health status

Excludes2: asymptomatic human immunodeficiency virus [HIV] infection status (Z21)

postprocedural status (Z93- Z99)

sex reassignment status (Z87.890)

Z78.0 Asymptomatic menopausal state

Menopausal state NOS

Postmenopausal status NOS

Excludes2: symptomatic menopausal state (N95.1)

Z78.9 Other specified health status

Z79 Long term (current) drug therapy

Includes: long term (current) drug use for prophylactic purposes

Code also any therapeutic drug level monitoring (Z51.81)

Excludes2: drug abuse and dependence (F11-F19)

drug use complicating pregnancy, childbirth, and the puerperium (O99.32-)

Z79.0 Long term (current) use of anticoagulants and antithrombotics/antiplatelets

Excludes2: long term (current) use of aspirin (Z79.83)

Z79.01 Long term (current) use of anticoagulants

Z79.02 Long term (current) use of antithrombotics/antiplatelets

Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID)

Excludes2: long term (current) use of aspirin (Z79.82)

Z79.2 Long term (current) use of antibiotics

Z79.3 Long term (current) use of hormonal contraceptives

Long term (current) use of birth control pill or patch

Z79.4 Long term (current) use of insulin

Z79.5 Long term (current) use of steroids

Z79.51 Long term (current) use of inhaled steroids

Z79.52 Long term (current) use of systemic steroids

Z79.8 Other long term (current) drug therapy

Z79.81 Long term (current) use of agents affecting estrogen receptors and estrogen levels

Code first, if applicable:

malignant neoplasm of breast (C50.-)

malignant neoplasm of prostate (C61)

Use additional 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)

Excludes1: hormone replacement therapy (postmenopausal) (Z79.890)

Z79.810 Long term (current) use of selective estrogen receptor modulators (SERMs)

Long term (current) use of raloxifene (Evista)

Long term (current) use of tamoxifen (Nolvadex)

Long term (current) use of toremifene (Fareston)

Z79.811 Long term (current) use of aromatase inhibitors

Long term (current) use of anastrozole (Arimidex)

Long term (current) use of exemestane (Aromasin)

Long term (current) use of letrozole (Femara)

Z79.818 Long term (current) use of other agents affecting estrogen receptors and estrogen levels

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)

Z79.82 Long term (current) use of aspirin

Z79.89 Other long term (current) drug therapy

Z79.890 Hormone replacement therapy (postmenopausal)

Z79.891 Long term (current) use of opiate analgesic

Long term (current) use of methadone for pain management

Excludes1: methodone use NOS (F11.2-)

use of methodone for treatment of heroin addiction (F11.2-)

Z79.899 Other long term (current) drug therapy

Z80 Family history of primary malignant neoplasm

Z80.0 Family history of malignant neoplasm of digestive organs

Conditions classifiable to C15-C26

Z80.1 Family history of malignant neoplasm of trachea, bronchus and lung

Conditions classifiable to C33-C34

Z80.2 Family history of malignant neoplasm of other respiratory and intrathoracic organs

Conditions classifiable to C30-C32, C37-C39

Z80.3 Family history of malignant neoplasm of breast

Conditions classifiable to C50.-

Z80.4 Family history of malignant neoplasm of genital organs

Conditions classifiable to C51-C63

Z80. 41 Family history of malignant neoplasm of ovary

Z80.42 Family history of malignant neoplasm of prostate

Z80.43 Family history of malignant neoplasm of testis

Z80.49 Family history of malignant neoplasm of other genital organs

Z80.5 Family history of malignant neoplasm of urinary tract

Conditions classifiable to C64-C68

Z80.51 Family history of malignant neoplasm of kidney

Z80.52 Family history of malignant neoplasm of bladder

Z80.59 Family history of malignant neoplasm of other urinary tract organ

Z80.6 Family history of leukemia

Conditions classifiable to C91-C95

Z80.7 Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Conditions classifiable to C81-C90, C96.-

Z80.8 Family history of malignant neoplasm of other organs or systems

Conditions classifiable to C00-C14, C40-C49, C69-C79

Z80.9 Family history of malignant neoplasm, unspecified

Conditions classifiable to C80.1

Z81 Family history of mental and behavioral disorders

Z81.0 Family history of mental retardation

Conditions classifiable to F70-F79

Z81.1 Family history of alcohol abuse and dependence

Conditions classifiable to F10.-

Z81.2 Family history of tobacco abuse and dependence

Conditions classifiable to F17.-

Z81.3 Family history of other psychoactive substance abuse and dependence

Conditions classifiable to F11-F16, F18-F19

Z81.4 Family history of other substance abuse and dependence

Conditions classifiable to F55

Z81.8 Family history of other mental and behavioral disorders

Conditions classifiable elsewhere in F01-F99

Z82 Family history of certain disabilities and chronic diseases (leading to disablement)

Z82.0 Family history of epilepsy and other diseases of the nervous system

Conditions classifiable to G00-G99

Z82.1 Family history of blindness and visual loss

Conditions classifiable to H54.-

Z82.2 Family history of deafness and hearing loss

Conditions classifiable to H90-H91

Z82.3 Family history of stroke

Conditions classifiable to I60-I64

Z82.4 Family history of ischemic heart disease and other diseases of the circulatory system

Conditions classifiable to I00-I52, I65-I99

Z82.41 Family history of sudden cardiac death

Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system

Z82.5 Family history of asthma and other chronic lower respiratory diseases

Conditions classifiable to J40-J47

Excludes2: family history of other diseases of the respiratory system (Z83.6)

Z82.6 Family history of arthritis and other diseases of the musculoskeletal system and connective tissue

Conditions classifiable to M00-M99

Z82.61 Family history of arthritis

Z82.62 Family history of osteoporosis

Z82.69 Family history of other diseases of the musculoskeletal system and connective tissue

Z82.7 Family history of congenital malformations, deformations and chromosomal abnormalities

Conditions classifiable to Q00-Q99

Z82.71 Family history of polycystic kidney

Z82.79 Family history of other congenital malformations, deformations and chromosomal abnormalities

Z82.8 Family history of other disabilities and chronic diseases leading to disablement, not elsewhere classified

Z83 Family history of other specific disorders

Excludes2: contact with and (suspected) exposure to communicable disease in the family (Z20.-)

Z83.0 Family history of human immunodeficiency virus [HIV] disease

Conditions classifiable to B20

Z83.1 Family history of other infectious and parasitic diseases

Conditions classifiable to A00-B19, B25-B94, B99

Z83.2 Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Conditions classifiable to D50-D89

Z83.3 Family history of diabetes mellitus

Conditions classifiable to E09-E13

Z83.4 Family history of other endocrine, nutritional and metabolic diseases

Conditions classifiable to E00-E07, E15-E90

Z83.41 Family history of multiple endocrine neoplasia [MEN] syndrome

Z83. 49 Family history of other endocrine, nutritional and metabolic diseases

Z83.5 Family history of eye and ear disorders

Conditions classifiable to H00-H53, H55-H83, H92-H95

Excludes2: family history of blindness and visual loss (Z82.1)

family history of deafness and hearing loss (Z82.2)

Z83.6 Family history of other diseases of the respiratory system

Conditions classifiable to J00-J39, J60-J99

Excludes2: family history of asthma and other chronic lower respiratory diseases (Z82.5)

Z83.7 Family history of diseases of the digestive system

Conditions classifiable to K00-K93

Z83.71 Family history of colonic polyps

Excludes1: family history of malignant neoplasm of digestive organs (Z80.0)

Z83.79 Family history of other diseases of the digestive system

Z84 Family history of other conditions

Z84.0 Family history of diseases of the skin and subcutaneous tissue

Conditions classifiable to L00-L99

Z84.1 Family history of disorders of kidney and ureter

Conditions classifiable to N00-N29

Z84.2 Family history of other diseases of the genitourinary system

Conditions classifiable to N30-N99

Z84.3 Family history of consanguinity

Z84.8 Family history of other specified conditions

Z84.81 Family history of carrier of genetic disease

Z84.89 Family history of other specified conditions

Z85 Personal history of malignant neoplasm

Code first any follow-up examination after treatment of malignant neoplasm (Z08)

Use additional code to identify:

alcohol use and dependence (F10.-)

exposure to environmental tobacco smoke (Z77.22)

history of tobacco use (Z87.891)

occupational exposure to environmental tobacco smoke (Z57.31)

tobacco dependence (F17.-)

tobacco use (Z72.0)

Excludes2: personal history of benign neoplasm (Z86.01-)

personal history of carcinoma-in-situ (Z86.00-)

Z85.0 Personal history of malignant neoplasm of digestive organs

Z85.00 Personal history of malignant neoplasm of unspecified digestive organ

Z85.01 Personal history of malignant neoplasm of esophagus

Conditions classifiable to C15

Z85. 02 Personal history of malignant neoplasm of stomach

Z85.020 Personal history of malignant carcinoid tumor of stomach

Conditions classifiable to C7a.092

Z85.028 Personal history of other malignant neoplasm of stomach

Conditions classifiable to C16

Z85.03 Personal history of malignant neoplasm of large intestine

Z85.030 Personal history of malignant carcinoid tumor of large intestine

Conditions classifiable to C7a.022-C7a.025, C7a.029

Z85.038 Personal history of other malignant neoplasm of large intestine

Conditions classifiable to C18

Z85.04 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus

Z85.040 Personal history of malignant carcinoid tumor of rectum

Conditions classifiable to C7a.026

Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus

Conditions classifiable to C19-C21

Z85.05 Personal history of malignant neoplasm of liver

Conditions classifiable to C22

Z85.06 Personal history of malignant neoplasm of small intestine

Z85.060 Personal history of malignant carcinoid tumor of small intestine

Conditions classifiable to C7a.01-

Z85.068 Personal history of other malignant neoplasm of small intestine

Conditions classifiable to C17

Z85.07 Personal history of malignant neoplasm of pancreas

Conditions classifiable to C25

Z85.09 Personal history of malignant neoplasm of other digestive organs

Z85.1 Personal history of malignant neoplasm of trachea, bronchus and lung

Z85.11 Personal history of malignant neoplasm of bronchus and lung

Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung

Conditions classifiable to C7a.090

Z85.118 Personal history of other malignant neoplasm of bronchus and lung

Conditions classifiable to C34

Z85.12 Personal history of malignant neoplasm of trachea

Conditions classifiable to C33

Z85.2 Personal history of malignant neoplasm of other respiratory and intrathoracic organs

Z85.20 Personal history of malignant neoplasm of unspecified respiratory organ

Z85.21 Personal history of malignant neoplasm of larynx

Conditions classifiable to C32

Z85.22 Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses

Conditions classifiable to C30-C31

Z85.23 Personal history of malignant neoplasm of thymus

Z85.230 Personal history of malignant carcinoid tumor of thymus

Conditions classifiable to C7a.091

Z85.238 Personal history of malignant neoplasm of thymus

Conditions classifiable to C37

Z85.29 Personal history of malignant neoplasm of other respiratory and intrathoracic organs

Z85.3 Personal history of malignant neoplasm of breast

Conditions classifiable to C50.-

Z85.4 Personal history of malignant neoplasm of genital organs

Conditions classifiable to C51-C63

Z85.40 Personal history of malignant neoplasm of unspecified female genital organ

Z85.41 Personal history of malignant neoplasm of cervix uteri

Z85.42 Personal history of malignant neoplasm of other parts of uterus

Z85.43 Personal history of malignant neoplasm of ovary

Z85.44 Personal history of malignant neoplasm of other female genital organs

Z85.45 Personal history of malignant neoplasm of unspecified male genital organ

Z85.46 Personal history of malignant neoplasm of prostate

Z85.47 Personal history of malignant neoplasm of testis

Z85.48 Personal history of malignant neoplasm of epididymis

Z85.49 Personal history of malignant neoplasm of other male genital organs

Z85.5 Personal history of malignant neoplasm of urinary tract

Conditions classifiable to C64-C68

Z85. 50 Personal history of malignant neoplasm of unspecified urinary tract organ

Z85.51 Personal history of malignant neoplasm of bladder

Z85.52 Personal history of malignant neoplasm of kidney

Excludes1: personal history of malignant neoplasm of renal pelvis (Z85.53)

Z85.520 Personal history of malignant carcinoid tumor of kidney

Conditions classifiable to C7a.093

Z85.528 Personal history of other malignant neoplasm of kidney

Conditions classifiable to C64

Z85.53 Personal history of malignant neoplasm of renal pelvis

Z85.59 Personal history of malignant neoplasm of other urinary tract organ

Z85.6 Personal history of leukemia

Conditions classifiable to C91-C95

Excludes1: leukemia in remission C91.0-C95.9 with 5th character 1

Z85.7 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Z85.71 Personal history of Hodgkin lymphoma

Conditions classifiable to C81

Z85.72 Personal history of non-Hodgkin lymphomas

Conditions classifiable to C82-C85

Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Conditions classifiable to C88-C90, C96

Excludes1: multiple myeloma in remission (C90.01)

plasma cell leukemia in remission (C90.11)

plasmacytoma in remission (C90.21)

Z85.8 Personal history of malignant neoplasms of other organs and systems

Conditions classifiable to C00-C14, C40-C49, C69-C79, C7a.098

Z85.81 Personal history of malignant neoplasm of lip, oral cavity, and pharynx

Z85.810 Personal history of malignant neoplasm of tongue

Z85.818 Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx

Z85.819 Personal history of malignant neoplasm of unspecified site of lip, oral cavity, and pharynx

Z85.82 Personal history of malignant neoplasm of skin

Z85. 820 Personal history of malignant melanoma of skin

Conditions classifiable to C43

Z85.821 Personal history of Merkel cell carcinoma

Conditions classifiable to C4a

Z85.828 Personal history of other malignant neoplasm of skin

Conditions classifiable to C44

Z85.83 Personal history of malignant neoplasm of bone and soft tissue

Z85.830 Personal history of malignant neoplasm of bone

Z85.831 Personal history of malignant neoplasm of soft tissue

Excludes2: personal history of malignant neoplasm of skin (Z85.82-)

Z85.84 Personal history of malignant neoplasm of eye and nervous tissue

Z85.840 Personal history of malignant neoplasm of eye

Z85.841 Personal history of malignant neoplasm of brain

Z85.848 Personal history of malignant neoplasm of other parts of nervous tissue

Z85.85 Personal history of malignant neoplasm of endocrine glands

Z85.850 Personal history of malignant neoplasm of thyroid

Z85.858 Personal history of malignant neoplasm of other endocrine glands

Z85.89 Personal history of malignant neoplasm of other organs and systems

Z85.9 Personal history of malignant neoplasm, unspecified

Conditions classifiable to C7a.00, C80.1

Z86 Personal history of certain other diseases

Code first any follow-up examination after treatment (Z09)

Z86.0 Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior

Excludes2: personal history of malignant neoplasms (Z85.-)

Z86.00 Personal history of in-situ neoplasm

Z86.000 Personal history of in-situ neoplasm of breast

Z86.001 Personal history of in-situ neoplasm of cervix uteri

Z86.008 Personal history of in-situ neoplasm of other site

Z86. 01 Personal history of benign neoplasm

Z86.010 Personal history of colonic polyps

Z86.011 Personal history of benign neoplasm of the brain

Z86.012 Personal history of benign carcinoid tumor

Z86.018 Personal history of other benign neoplasm

Z86.03 Personal history of neoplasm of uncertain behavior

Z86.1 Personal history of infectious and parasitic diseases

Conditions classifiable to A00-B89, B99

Excludes1: personal history of infectious diseases specific to a body system

sequelae of infectious and parasitic diseases (B90-B94)

Z86.11 Personal history of tuberculosis

Z86.12 Personal history of poliomyelitis

Z86.13 Personal history of malaria

Z86.19 Personal history of other infectious and parasitic diseases

Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Conditions classifiable to D50-D89

Z86.3 Personal history of endocrine, nutritional and metabolic diseases

Conditions classifiable to E00-E90

Z86.31 Personal history of diabetic foot ulcer

Excludes2: current diabetic foot ulcer (E09.640, E10.640, E11.640, E13.640)

Z86.39 Personal history of other endocrine, nutritional and metabolic disease

Z86.6 Personal history of diseases of the nervous system and sense organs

Conditions classifiable to G00-G99, H00-H95

Z86.61 Personal history of infections of the central nervous system

Personal history of encephalitis

Personal history of meningitis

Z86.69 Personal history of other diseases of the nervous system and sense organs

Z86.7 Personal history of diseases of the circulatory system

Conditions classifiable to I00-I99

Excludes2: old myocardial infarction (I25.2)

postmyocardial infarction syndrome (I24.1)

Z86.71 Personal history of venous thrombosis and embolism

Z86.72 Personal history of thrombophlebitis

Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

Personal history of prolonged reversible ischemic neurological deficit (PRIND)

Personal history of stroke NOS without residual deficits

Excludes1: personal history of traumatic brain injury (Z87.820)

sequelae of cerebrovascular disease (I69.-)

Z86.74 Personal history of sudden cardiac arrest

Personal history of sudden cardiac death sucessfully resuscitated

Z86.79 Personal history of other diseases of the circulatory system

Z87 Personal history of other diseases and conditions

Code first any: follow-up examination after treatment (Z09)

Z87.0 Personal history of diseases of the respiratory system

Conditions classifiable to J00-J99

Z87.01 Personal history of pneumonia (recurrent)

Z87.09 Personal history of other diseases of the respiratory system

Z87.1 Personal history of diseases of the digestive system

Conditions classifiable to K00-K93

Z87.11 Personal history of peptic ulcer disease

Z87.19 Personal history of other diseases of the digestive system

Z87.2 Personal history of diseases of the skin and subcutaneous tissue

Conditions classifiable to L00-L99

Excludes2: personal history of diabetic foot ulcer (Z86.31)

Z87.3 Personal history of diseases of the musculoskeletal system and connective tissue

Conditions classifiable to M00-M99

Excludes2: personal history of (healed) traumatic fracture (Z87.81)

Z87.31 Personal history of (healed) nontraumatic fracture

Z87.310 Personal history of (healed) osteoporosis fracture

Personal history of (healed) fragility fracture

Personal history of (healed) collapsed vertebra due to osteoporosis

Z87.311 Personal history of (healed) other pathological fracture

Personal history of (healed) collapsed vertebra NOS

Excludes2: personal history of osteoporosis fracture (Z87.310)

Z87.312 Personal history of (healed) stress fracture

Personal history of (healed) fatigue fracture

Z87. 39 Personal history of other diseases of the musculoskeletal system and connective tissue

Z87.4 Personal history of diseases of the genitourinary system

Conditions classifiable to N00-N99

Z87.41 Personal history of urinary (tract) infection(s)

Z87.42 Personal history of nephrotic syndrome

Z87.43 Personal history of urinary calculi

Z87.44 Personal history of cervical dysplasia

Excludes1: personal history of malignant neoplasm of cervix uteri (Z85.41)

Z87.49 Personal history of other diseases of the genitourinary system

Z87.5 Personal history of complications of pregnancy, childbirth and the puerperium

Conditions classifiable to O00-O99

Excludes2: habitual aborter (N96)

Z87.51 Personal history of pre-term labor

Excludes1: current pregnancy with history of pre-term labor (O09.21-)

Z87.59 Personal history of other complications of pregnancy, childbirth and the puerperium

Personal history of trophoblastic disease

Z87.7 Personal history of congenital malformations and deformations

Conditions classifiable to Q00-Q89 that have been repaired or corrected

Z87.71 Personal history of hypospadias

Z87.79 Personal history of other congenital malformations and deformations

Z87.8 Personal history of other specified conditions

Excludes2: personal history of self harm (Z91.5)

Z87.81 Personal history of (healed) traumatic fracture

Excludes2: personal history of (healed) nontraumatic fracture (Z87.31-)

Z87.82 Personal history of other (healed) physical injury and trauma

Conditions classifiable to S00-T98, except traumatic fractures

Z87.820 Personal history of traumatic brain injury

Excludes1: personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (Z86.73)

Z87.828 Personal history of other (healed) physical injury and trauma

Z87.89 Personal history of other specified conditions

Z87.890 Personal history of sex reassignment

Z87. 891 Personal history of nicotine dependence

Excludes1: current nicotine dependence (F17.2-)

Z87.898 Personal history of other specified conditions

Z88 Allergy status to drugs, medicaments and biological substances

Excludes2: Allergy status, other than to drugs and biological substances (Z91.0-)

Z88.0 Allergy status to penicillin

Z88.1 Allergy status to other antibiotic agents status

Z88.2 Allergy status to sulfonamides status

Z88.3 Allergy status to other anti-infective agents status

Z88.4 Allergy status to anesthetic agent status

Z88.5 Allergy status to narcotic agent status

Z88.6 Allergy status to analgesic agent status

Z88.7 Allergy status to serum and vaccine status

Z88.8 Allergy status to other drugs, medicaments and biological substances status

Z88.9 Allergy status to unspecified drugs, medicaments and biological substances status

Z89 Acquired absence of limb

Includes: amputation status

postprocedural loss of limb

post-traumatic loss of limb

Excludes1: acquired deformities of limbs (M20-M21)

congenital absence of limbs (Q71-Q73)

Z89.0 Acquired absence of thumb and other finger(s)

Z89.01 Acquired absence of thumb

Z89.011 Acquired absence of right thumb

Z89.012 Acquired absence of left thumb

Z89.019 Acquired absence of unspecified thumb

Z89.02 Acquired absence of other finger(s)

Excludes2: acquired absence of thumb (Z89.01-)

Z89.021 Acquired absence of right finger(s)

Z89.022 Acquired absence of left finger(s)

Z89.029 Acquired absence of unspecified finger(s)

Z89.1 Acquired absence of hand and wrist

Z89.11 Acquired absence of hand

Z89.111 Acquired absence of right hand

Z89.112 Acquired absence of left hand

Z89.119 Acquired absence of unspecified hand

Z89.12 Acquired absence of wrist

Disarticulation at wrist

Z89.121 Acquired absence of right wrist

Z89.122 Acquired absence of left wrist

Z89. 129 Acquired absence of unspecified wrist

Z89.2 Acquired absence of upper limb above wrist

Z89.20 Acquired absence of upper limb, unspecified level

Z89.201 Acquired absence of right upper limb, unspecified level

Z89.202 Acquired absence of left upper limb, unspecified level

Z89.209 Acquired absence of unspecified upper limb, unspecified level

Acquired absence of arm NOS

Z89.21 Acquired absence of upper limb below elbow

Z89.211 Acquired absence of right upper limb below elbow

Z89.212 Acquired absence of left upper limb below elbow

Z89.219 Acquired absence of unspecified upper limb below elbow

Z89.22 Acquired absence of upper limb above elbow

Disarticulation at elbow

Z89.221 Acquired absence of right upper limb above elbow

Z89.222 Acquired absence of left upper limb above elbow

Z89.229 Acquired absence of unspecified upper limb above elbow

Z89.23 Acquired absence of shoulder

Z89.231 Acquired absence of right shoulder

Z89.232 Acquired absence of left shoulder

Z89.239 Acquired absence of unspecified shoulder

Z89.4 Acquired absence of toe(s), foot, and ankle

Z89.41 Acquired absence of great toe

Z89.411 Acquired absence of right great toe

Z89.412 Acquired absence of left great toe

Z89.419 Acquired absence of unspecified great toe

Z89.42 Acquired absence of other toe(s)

Excludes2: acquired absence of great toe (Z89.41-)

Z89.421 Acquired absence of other right toe(s)

Z89.422 Acquired absence of other left toe(s)

Z89.429 Acquired absence of other toe(s), unspecified side

Z89.43 Acquired absence of foot

Z89.431 Acquired absence of right foot

Z89.432 Acquired absence of left foot

Z89. 439 Acquired absence of unspecified foot

Z89.44 Acquired absence of ankle

Disarticulation of ankle

Z89.441 Acquired absence of right ankle

Z89.442 Acquired absence of left ankle

Z89.449 Acquired absence of unspecified ankle

Z89.5 Acquired absence of leg below knee

Z89.50 Acquired absence of leg knee, unspecified side

Z89.51 Acquired absence of right leg below knee

Z89.52 Acquired absence of left leg below knee

Z89.6 Acquired absence of leg above knee

Z89.61 Acquired absence of leg above knee

Acquired absence of leg NOS

Disarticulation at knee

Z89.611 Acquired absence of right leg above knee

Z89.612 Acquired absence of left leg above knee

Z89.619 Acquired absence of unspecified leg above knee

Z89.62 Acquired absence of hip

Disarticulation at hip

Z89.621 Acquired absence of right hip

Z89.622 Acquired absence of left hip

Z89.629 Acquired absence of unspecified hip

Z89.9 Acquired absence of limb, unspecified

Z90 Acquired absence of organs, not elsewhere classified

Includes: postprocedural or post-traumatic loss of body part NEC

Excludes1: congenital absence - see Alphabetical Index

Excludes2: postprocedural absence of endocrine glands (E89.-)

Z90.0 Acquired absence of part of head and neck

Z90.01 Acquired absence of eye

Z90.02 Acquired absence of larynx

Z90.09 Acquired absence of other part of head and neck

Acquired absence of nose

Excludes2: teeth (K08.1)

Z90.1 Acquired absence of breast and nipple

Z90.10 Acquired absence of unspecified breast and nipple

Z90.11 Acquired absence of right breast and nipple

Z90.12 Acquired absence of left breast and nipple

Z90.13 Acquired absence of bilateral breasts and nipples

Z90.2 Acquired absence of lung [part of]

Z90.3 Acquired absence of stomach [part of]

Z90.4 Acquired absence of other parts of digestive tract

Z90.5 Acquired absence of kidney

Z90.6 Acquired absence of other parts of urinary tract

Acquired absence of bladder

Z90.7 Acquired absence of genital organ(s)

Excludes1: personal history of sex reassignment (Z87.890)

Excludes2: female genital mutilation status (N90.81-)

Z90.71 Acquired absence of cervix and uterus

Z90.710 Acquired absence of both cervix and uterus

Acquired absence of uterus NOS

Status post total hysterectomy

Z90.711 Acquired absence of uterus with remaining cervical stump

Status post partial hysterectomy with remaining cervical stump

Z90.712 Acquired absence of cervix with remaining uterus

Z90.72 Acquired absence of ovaries

Z90.721 Acquired absence of ovaries, unilateral

Z90.722 Acquired absence of ovaries, bilateral

Z90.79 Acquired absence of other genital organ(s)

Z90.8 Acquired absence of other organs

Z90.81 Acquired absence of spleen

Z90.89 Acquired absence of other organs

Z91 Personal risk factors, not elsewhere classified

Excludes2: contact with and (suspected) exposures hazardous to health (Z77.-)

exposure to pollution and other problems related to physical environment (Z77.1-)

personal history of physical injury and trauma (Z87.81, Z87.82-)

occupational exposure to risk factors (Z57.-)

Z91.0 Allergy status, other than to drugs and biological substances

Excludes2: Allergy status to drugs, medicaments, and biological substances (Z88.-)

Z91.01 Food allergy status

Excludes2: food additives allergy status (Z91.02)

Z91.010 Allergy to peanuts

Z91.011 Allergy to milk products

Excludes1: lactose intolerance (E73.-)

Z91.012 Allergy to eggs

Z91.013 Allergy to seafood

Allergy to shellfish

Allergy to octopus or squid ink

Z91.018 Allergy to other foods

Allergy to nuts other than peanuts

Z91.02 Food additives allergy status

Z91.03 Insect allergy status

Z91.030 Bee allergy status

Z91.038 Other insect allergy status

Z91.04 Nonmedicinal substance allergy status

Z91.040 Latex allergy status

Latex sensitivity status

Z91. 041 Radiographic dye allergy status

Allergy status to contrast media used for diagnostic x-ray procedure

Z91.048 Other nonmedicinal substance allergy status

Z91.09 Other allergy status, other than to drugs and biological substances

Z91.1 Patient's noncompliance with medical treatment and regimen

Z91.11 Patient's noncompliance with dietary regimen

Z91.12 Patient's intentional underdosing of medication regimen

Code first underdosing of medication (T36-T50) with fifth or sixth character 6

Excludes1: adverse effect of prescribed drug taken as directed- code to adverse effect

poisoning (overdose) -code to poisoning

Z91.120 Patient's intentional underdosing of medication regimen due to financial hardship

Z91.128 Patient's intentional underdosing of medication regimen for other reason

Z91.13 Patient's unintentional underdosing of medication regimen

Code first underdosing of medication (T36-T50) with fifth or sixth character 6

Excludes1: adverse effect of prescribed drug taken as directed- code to adverse effect

poisoning (overdose) -code to poisoning

Z91.130 Patient's unintentional underdosing of medication regimen due to age-related debility

Z91.138 Patient's unintentional underdosing of medication regimen for other reason

Z91.14 Patient's other noncompliance with medication regimen

Patient's underdosing of medication NOS

Z91.15 Patient's noncomplicance with renal dialysis

Z91.19 Patient's noncompliance with other medical treatment and regimen

Z91.4 Personal history of psychological trauma, not elsewhere classified

Z91.41 Personal history of adult abuse

Excludes2: personal history of abuse in childhood (Z62.81-)

Z91.410 Personal history of adult physical and sexual abuse

Excludes1: current adult physical abuse (T74.11, T76.11)

current adult sexual abuse (T74. 21, T76.11)

Z91.411 Personal history of adult psychological abuse

Z91.412 Personal history of adult neglect

Excludes1: current adult neglect (T74.01, T76.01)

Z91.419 Personal history of unspecified adult abuse

Z91.49 Other personal history of psychological trauma, not elsewhere classified

Z91.5 Personal history of self-harm

Personal history of parasuicide

Personal history of self-poisoning

Personal history of suicide attempt

Z91.8 Other specified personal risk factors, not elsewhere classified

Z91.81 History of falling

At risk for falling

Z91.82 Personal history of military deployment

Individual (civilian or military) with past history of military war, peacekeeping and humanitarian deployment (current or past conflict)

Returned from military deployment

Z91.89 Other specified personal risk factors, not elsewhere classified

Z92 Personal history of medical treatment

Excludes2: postprocedural states (Z98.-)

Z92.0 Personal history of contraception

Excludes1: counseling or management of current contraceptive practices (Z30.-)

long term (current) use of contraception (Z79.3)

presence of (intrauterine) contraceptive device (Z97.5)

Z92.2 Personal history of drug therapy

Excludes2: long term (current) drug therapy (Z79.-)

Z92.21 Personal history of antineoplastic chemotherapy

Z92.22 Personal history of monoclonal drug therapy

Z92.23 Personal history of estrogen therapy

Z92.24 Personal history of steroid therapy

Z92.240 Personal history of inhaled steroid therapy

Z92.241 Personal history of systemic steroid therapy

Personal history of steroid therapy NOS

Z92.25 Personal history of immunosupression therapy

Excludes2: personal history of steroid therapy (Z92.24)

Z92.29 Personal history of other drug therapy

Z92.3 Personal history of irradiation

Personal history of exposure to therapeutic radiation

Excludes1: exposure to radiation in the physical environment (Z77.12)

occupational exposure to radiation (Z57.1)

Z92.8 Personal history of other medical treatment

Z92.81 Personal history of extracorporeal membrane oxygenation (ECMO)

Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility

Code first condition requiring tPA administration, such as:

acute cerebral infarction (I63.-)

acute myocardial infarction (I21.-, I22.-)

Z92.83 Personal history of failed moderate sedation

Personal history of failed conscious sedation

Excludes2: failed moderate sedation during procedure (T88.52)

Z92.89 Personal history of other medical treatment

Z93 Artificial opening status

Excludes1: artificial openings requiring attention or management (Z43.-)

complications of external stoma (J95.0-, K91.4-, K91.7-, N99.5-)

Z93.0 Tracheostomy status

Z93.1 Gastrostomy status

Z93.2 Ileostomy status

Z93.3 Colostomy status

Z93.4 Other artificial openings of gastrointestinal tract status

Z93.5 Cystostomy status

Z93.50 Unspecified cystostomy status

Z93.51 Cutaneous-vesicostomy status

Z93.52 Appendico-vesicostomy status

Z93.59 Other cystostomy status

Z93.6 Other artificial openings of urinary tract status

Nephrostomy status

Ureterostomy status

Urethrostomy status

Z93.8 Other artificial opening status

Z93.9 Artificial opening status, unspecified

Z94 Transplanted organ and tissue status

Includes: organ or tissue replaced by heterogenous or homogenous transplant

Excludes1: complications of transplanted organ or tissue - see Alphabetical Index

Excludes2: presence of vascular grafts (Z95.-)

Z94.0 Kidney transplant status

Z94.1 Heart transplant status

Excludes1: artificial heart status (Z95.811)

heart-valve replacement status (Z95.2-Z95.4)

Z94.2 Lung transplant status

Z94. 3 Heart and lungs transplant status

Z94.4 Liver transplant status

Z94.5 Skin transplant status

Autogenous skin transplant status

Z94.6 Bone transplant status

Z94.7 Corneal transplant status

Z94.8 Other transplanted organ and tissue status

Z94.81 Bone marrow transplant status

Z94.82 Intestine transplant status

Z94.83 Pancreas transplant status

Z94.84 Stem cells transplant status

Z94.89 Other transplanted organ and tissue status

Z94.9 Transplanted organ and tissue status, unspecified

Z95 Presence of cardiac and vascular implants and grafts

Excludes1: complications of cardiac and vascular devices, implants and grafts (T82.-)

Z95.0 Presence of cardiac pacemaker

Excludes1: adjustment or management of cardiac pacemaker (Z45.0)

Z95.1 Presence of aortocoronary bypass graft

Z95.2 Presence of prosthetic heart valve

Presence of heart valve NOS

Z95.3 Presence of xenogenic heart valve

Z95.4 Presence of other heart-valve replacement

Z95.5 Presence of coronary angioplasty implant and graft

Excludes1: coronary angioplasty status without implant and graft (Z98.61)

Z95.8 Presence of other cardiac and vascular implants and grafts

Z95.81 Presence of other cardiac implants and grafts

Z95.810 Presence of automatic (implantable) cardiac defibrillator

Z95.811 Presence of heart assist device

Z95.812 Presence of fully implantable artificial heart

Z95.818 Presence of other cardiac implants and grafts

Z95.82 Presence of other vascular implants and grafts

Z95.820 Peripheral vascular angioplasty status with implants and grafts

Excludes1: peripheral vascular angioplasty without implant and graft (Z98.62)

Z95.828 Presence of other vascular implants and grafts

Presence of intravascular prosthesis NEC

Z95. 9 Presence of cardiac and vascular implant and graft, unspecified

Z96 Presence of other functional implants

Excludes1: complications of internal prosthetic devices, implants and grafts (T82-T85)

fitting and adjustment of prosthetic and other devices (Z44-Z46)

Z96.0 Presence of urogenital implants

Z96.1 Presence of intraocular lens

Presence of pseudophakia

Z96.2 Presence of otological and audiological implants

Z96.20 Presence of otological and audiological implant, unspecified

Z96.21 Cochlear implant status

Z96.22 Myringotomy tube(s) status

Z96.29 Presence of other otological and audiological implants

Presence of bone-conduction hearing device

Presence of eustachian tube stent

Stapes replacement

Z96.3 Presence of artificial larynx

Z96.4 Presence of endocrine implants

Z96.41 Presence of insulin pump (external) (internal)

Z96.49 Presence of other endocrine implants

Z96.5 Presence of tooth-root and mandibular implants

Z96.6 Presence of orthopedic joint implants

Z96.60 Presence of unspecified orthopedic joint implant

Z96.61 Presence of artificial shoulder joint

Z96.611 Presence of right artificial shoulder joint

Z96.612 Presence of left artificial shoulder joint

Z96.619 Presence of unspecified artificial shoulder joint

Z96.62 Presence of artificial elbow joint

Z96.621 Presence of right artificial elbow joint

Z96.622 Presence of left artificial elbow joint

Z96.629 Presence of unspecified artificial elbow joint

Z96.63 Presence of artificial wrist joint

Z96.631 Presence of right artificial wrist joint

Z96.632 Presence of left artificial wrist joint

Z96.639 Presence of unspecified artificial wrist joint

Z96.64 Presence of artificial hip joint

Hip-joint replacement (partial) (total)

Z96.641 Presence of right artificial hip joint

Z96.642 Presence of left artificial hip joint

Z96.643 Presence of artificial hip joint, bilateral

Z96.649 Presence of unspecified artificial hip joint

Z96.65 Presence of artificial knee joint

Z96. 651 Presence of right artificial knee joint

Z96.652 Presence of left artificial knee joint

Z96.653 Presence of artificial knee joint, bilateral

Z96.659 Presence of unspecified artificial knee joint

Z96.66 Presence of artificial ankle joint

Z96.661 Presence of right artificial ankle joint

Z96.662 Presence of left artificial ankle joint

Z96.669 Presence of unspecified artificial ankle joint

Z96.69 Presence of other orthopedic joint implants

Z96.691 Finger-joint replacement of right hand

Z96.692 Finger-joint replacement of left hand

Z96.693 Finger-joint replacement, bilateral

Z96.698 Presence of other orthopedic joint implants

Z96.7 Presence of other bone and tendon implants

Presence of skull plate

Z96.8 Presence of other specified functional implants

Z96.81 Presence of artificial skin

Z96.89 Presence of other specified functional implants

Z96.9 Presence of functional implant, unspecified

Z97 Presence of other devices

Excludes1: complications of internal prosthetic devices, implants and grafts (T82-T85)

fitting and adjustment of prosthetic and other devices (Z44-Z46)

Excludes2: presence of cerebrospinal fluid drainage device (Z98.2)

Z97.0 Presence of artificial eye

Z97.1 Presence of artificial limb (complete) (partial)

Z97.10 Presence of artificial limb (complete) (partial), unspecified

Z97.11 Presence of artificial right arm (complete) (partial)

Z97.12 Presence of artificial left arm (complete) (partial)

Z97.13 Presence of artificial right leg (complete) (partial)

Z97.14 Presence of artificial left leg (complete) (partial)

Z97.15 Presence of artificial arms, bilateral (complete) (partial)

Z97.16 Presence of artificial legs, bilateral (complete) (partial)

Z97.2 Presence of dental prosthetic device (complete) (partial)

Presence of dentures (complete) (partial)

Z97.3 Presence of spectacles and contact lenses

Z97.4 Presence of external hearing-aid

Z97.5 Presence of (intrauterine) contraceptive device

Excludes1: checking, reinsertion or removal of contraceptive device (Z30.44)

Z97.8 Presence of other specified devices

Z98 Other postprocedural states

Excludes2: aftercare (Z43-Z49, Z51)

follow-up medical care (Z08- Z09)

postprocedural complication - see Alphabetical Index

Z98.0 Intestinal bypass and anastomosis status

Excludes2: bariatric surgery status (Z98.84)

gastric bypass status (Z98.84)

obesity surgery status (Z98.84)

Z98.1 Arthrodesis status

Z98.2 Presence of cerebrospinal fluid drainage device

Presence of CSF shunt

Z98.3 Post therapeutic collapse of lung status

Code first underlying disease

Z98.4 Cataract extraction status

Use additional code to identify intraocular lens implant status (Z96.1)

Excludes1: aphakia (H27.0)

Z98.41 Cataract extraction status, right eye

Z98.42 Cataract extraction status, left eye

Z98.49 Cataract extraction status, unspecified eye

Z98.5 Sterilization status

Excludes1: female infertility (N97.-)

male infertility (N46.-)

Z98.51 Tubal ligation status

Z98.52 Vasectomy status

Z98.6 Angioplasty status

Z98.61 Coronary angioplasty status

Excludes1: coronary angioplasty status with implant and graft (Z95.5)

Z98.62 Peripheral vascular angioplasty status

Excludes1: peripheral vascular angioplasty status with implant and graft (Z95.820)

Z98.8 Other specified postprocedural states

Z98.81 Dental procedure status

Z98.810 Dental sealant status

Z98.811 Dental restoration status

Dental crown status

Dental fillings status

Z98.818 Other dental procedure status

Z98.82 Breast implant status

Excludes1: breast implant removal status (Z98.86)

Z98.83 Filtering (vitreous) bleb after glaucoma surgery status

Excludes1: Inflammation (infection) of postprocedural bleb (H59.4-)

Z98.84 Bariatric surgery status

Gastric banding status

Gastric bypass status for obesity

Obesity surgery status

Excludes1: bariatric surgery status complicating pregnancy, childbirth, or the puerperium (O99.84)

Excludes2: intestinal bypass and anastomosis status (Z98.0)

Z98.85 Transplanted organ removal status

Transplanted organ previously removed due to complication, failure, rejection or infection

Excludes1: encounter for removal of transplanted organ -code to complication of transplanted organ (T86.-)

Z98.86 Personal history of breast implant removal

Z98.87 Personal history of in utero procedure

Z98.870 Personal history of in utero procedure during pregnancy

Excludes2: 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-)

Z98.871 Personal history of in utero procedure while a fetus

Z98.89 Other specified postprocedural states

Personal history of surgery, not elsewhere classified

Z99 Dependence on enabling machines and devices, not elsewhere classified

Excludes1: cardiac pacemaker status (Z95.0)

Z99.0 Dependence on aspirator

Z99.1 Dependence on respirator

Dependence on ventilator

Z99.11 Dependence on respirator [ventilator] status

Z99.12 Encounter for respirator [ventilator] dependence during power failure

Excludes1: mechanical complication of respirator [ventilator] (J95.850)

Z99.2 Dependence on renal dialysis

Hemodialysis status

Peritoneal dialysis status

Presence of arteriovenous shunt for dialysis

Renal dialysis status NOS

Excludes1: encounter for fitting and adjustment of dialysis catheter (Z49.0-)

noncompliance with renal dialysis (Z91.15)

Z99.3 Dependence on wheelchair