Some of the codes for routine health examinations distinguish between with and

Some of the codes for routine health examinations

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Some of the codes for routine health examinations distinguish between “with” and “without” abnormal findings. Code assignment depends on the information that is known at the time the encounter is being coded. For example, if no abnormal findings were found during the examination, but the encounter is being coded before test results are back, it is acceptable to assign the code for “without abnormal findings.” When assigning a code for “with abnormal findings,” additional code(s) should be assigned to identify the specific abnormal finding(s). Pre-operative examination and pre-procedural laboratory examination Z codes are for use only in those situations when a patient is being cleared for a procedure or surgery and no treatment is given. The Z codes/categories for routine and administrative examinations: Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Except: Z02.9, Encounter for administrative examinations, unspecified Z32.0- Encounter for pregnancy test 14)Miscellaneous Z codes The miscellaneous Z codes capture a number of other health care encounters that do not fall into one of the other categories. Certain of these codes identify the reason for the encounter; others are for use as additional codes that provide useful information on circumstances that may affect a patient’s care and treatment. Prophylactic organ removal For encounters specifically for prophylactic removal of an organ (such as prophylactic removal of breasts due to a genetic susceptibility to cancer or a family history of cancer), the principal or first-listed code should be a code from category Z40, Encounter for prophylactic surgery, followed by the appropriate codes to identify the associated risk factor (such as genetic susceptibility or family history). If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in addition to a code from subcategory Z40.0, Encounter for prophylactic surgery for risk factors related to malignant neoplasms. A Z40.0 code should not be assigned if the patient is having organ removal for treatment of a malignancy, such as the removal of the testes for the treatment of prostate cancer. Miscellaneous Z codes/categories: Z28 Immunization not carried out Except: Z28.3, Underimmunization status Z29 Encounter for other prophylactic measures Z40 Encounter for prophylactic surgery Z41 Encounter for procedures for purposes other than remedying health state Except: Z41.9, Encounter for procedure for purposes other than remedying health state, unspecified Z53 Persons encountering health services for specific procedures and treatment, not carried out Z55 Problems related to education and literacy Z56 Problems related to employment and unemployment Z57
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