10. Z38.62 Newborn, triplet, born in hospital, by cesarean P07.17 Low, birthweight, with weight of 1769 grams P07.38 Preterm, newborn, gestational age, 35 completed weeks The note that appears under category Z38, Liveborn infants according to place of birth and type of delivery, states 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. 11. Z20.2 Exposure (to) gonorrhea or Exposure (to) sexually-transmitted disease The main term of exposure (to) is used in the Alphabetic Index to locate the condition of the patient being exposed to or having contact with a partner who was known to have gonorrhea, a sexually transmitted disease. 12. Z30.2 Encounter (for), sterilization Z87.59 History, personal (of) obstetric complications Two reasons for the encounter are identified in this case. First the patient seeks permanent sterilization so the main reason for the encounter is for sterilization. The underlying reason for the sterilization is the fact that the patient had complications during her previous pregnancies. Main term of history, personal, obstetric complications is the approach to find the underlying reason for the sterilization in the ICD-10-CM codes. 13. Z52.3 Donor, bone, marrow Includes note under category Z52, Donors of Organs and Tissues, states the codes include autologous and other living donors. The Excludes1 instructs the coder that cadaveric donor—omit code so that none is assigned and examination of potential donor is classified with Z00.5. 14. Z01.419 Examination (for) cervical Papanicolaou smear, as part of routine gynecological examination Instructions appear under Z01.41, Encounter for routine gynecological examination to use additional code: (1) for screening for human papillomavirus, if applicable (Z11.51) (2) for screening vaginal pap smear, if applicable (Z12.72) (3) to identify acquire absence of uterus, if applicable (Z90.71-)
An Excludes1 note also appears to state what is not coded with Z01.41 codes, that is, gynecological examination status post hysterectomy for malignant condition (Z08) and screening cervical pap smear not a part of a routine gynecological examination (Z12.4). 15. Z08 Examination, following, treatment (for), chemotherapy, malignant neoplasm Z85.3 History, personal (of), malignant neoplasm (of), breast Z92.21 History, personal (of), chemotherapy for neoplastic condition The purpose of the visit is to perform a follow-up examination on a patient who has completed chemotherapy for breast cancer. Main term in the Alphabetic Index is a follow-up examination for the chemotherapy treatment. Under code Z08, Encounter for follow-up examination, is a note to use additional codes for the personal history malignant neoplasm of the breast. In addition, the coder must recognize the need for a code for the personal history of chemotherapy for the neoplastic condition the patient had.
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