PTSD Codig Fact Sheet

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PTSD Coding Fact Sheet

Updated 01/01/2016

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Current Procedural Terminology (CPT®) Codes
Initial assessment usually involves a lot of time determining the differential diagnosis, a diagnostic plan, and potential treatment options.  Therefore, most pediatricians will report either an office/outpatient evaluation and management (E/M) code using time as the key factor* or a consultation code for the initial assessment: 

Physician Evaluation & Management Services

​99201Office or other outpatient visit, new patient; self limited or minor problem, 10 min.
​99202​low to moderate severity problem, 20 min.
​99203​moderate severity problem, 30 min.
​99204​moderate to high severity problem, 45 min.
​99205​high severity problem, 60 min.
​A new patient is one whohas not received any professional face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s) from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belong to the same group practice, within the past three years.
​99211Office or other outpatient visit, established patient; minimal problem, 5 min. 
​99212​self limited or minor problem, 10 min.
​99213​low to moderate severity problem, 15 min.
​99214​moderate severity problem, 25 min.
​99215​moderate to high severity problem, 40 min.
992​41Office or other outpatient consultation, new or established patient; self-limited or minor problem, 15 min.
​99242​low severity problem, 30 min.
​99243​moderate severity problem, 45 min.
​99244​moderate to high severity problem, 60 min.
​99245​moderate to high severity problem, 80 min.

 

^NOTE: Use of these codes requires the following:
a) Written or verbal request for consultation is documented in the patient chart;
b) Consultant’s opinion as well as any services ordered or performed are documented in the patient chart; and
c) Consultant’s opinion and any services that are performed are prepared in a written report, which is sent to the requesting physician or other appropriate source (Note: Patients/Parents may not initiate a consultation)
d)For more information on consultation code changes for 2010 see AAP Position Paper.
 
Reporting E/M services using "Time"
  • When counseling or coordination of care dominates (more than 50%) the physician/patient or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. (CPT, Professional Edition, 2014, pg 10)
  • This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record. 
  • For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. 
  • When codes are ranked in sequential typical times (such as for the office-based E/M services or consulation codes) and the actual time is between 2 typical times, the code with the typical time closest to the actual time is used. 
  • Prolonged services can only be added to codes with listed typical times such as the one listed above. In order to report physician or other qualified health care professional prolonged services the reporting provider must spend a minimum of 30 minutes beyond the typical time listed in the code level being reported. When reporting outpatient prolonged services only count face-to-face time with the reporting provider. when reporting inpatient or observation prolonged services you can count face-to-face time, as well as unit/floor time spent on the patient's care. However, if the reporting provider is reporting their  services based on time (ie, counseling/coordinating care dominate) and not key components, then prolonged services cannot be reported unless the provider reaches 30 minutes beyond the listed typical time in the highest code in the set (eg, 99205, 99226, 99223). It is important that time is clearly noted in the patient's chart. For clinical staff prolonged services refer to CPT codes 99415-99416 in the CPT manual. 
​+99354Prolonged physician services in office or other outpatient setting, with direct patient contact; first hour (use in conjunction with time-based codes 99201-99215, 99241-99245, 99301-99350)
​+99355​each additional 30 min. (use in conjunction with 99354)
  • Used when a physician provides prolonged services beyond the usual service (ie, beyond the typical time).
  • Time spent does not have to be continuous. 
  • + Codes are “add-on” codes, meaning they are reported separately in addition to the appropriate code for the service provided (eg, office or other outpatient E/M codes, 99201-99215). 
  • Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. 

Physician Non-Face-to-Face Services

​99339Care Plan Oversight - Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
​99340​30 minutes or more 
​99358Prolonged physician services without direct patient contact; first hour NOTE: This code is no longer an “add-on” service and can be reported alone.
​+99359​each additional 30 min. (+ designated add-on code, use in conjunction with 99358)
​99367Medical team conference by physician with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more
​99441Telephone evaluation and management to an established patient, parent or guardian not originating from a related E/M service within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
​99442​11-20 minutes of medical discussion
​99443​21-30 minutes of medical discussion 
​99444 Online evaluation and management service provided by a physician or other qualified healthcare professional to an established patient, guardian or health care provider no originating from a related E/M service provided within the previous 7 days, using the internet or similar electronic communications network

 

Psychiatric Diagnostic or Evaluative Interview Procedures 

​90801Psychiatric diagnostic interview examination
90802

Interactive psychiatric diagnositc interview examination using play equipment, physical devices, language interpretation, or other communication mechanisms

Psychotherapy

90832Psychotherapy, 30 min with patient and/or family;
+90833​with medical evaluation and management  (Use in conjunction with 99201-99255, 99304-99337, 99341-99350)
​90834Psychotherapy, 45min with patient and/or family;
​+90836​with medical evaluation and management services  (Use in conjunction with 99201-99255, 99304-99337, 99341-99350)
90837Psychotherapy, 60 min with patient and/or family;
​+90838​with medical evaluation and management services (Use in conjunction with 99201-99255, 99304-99337, 99341-99350)
​+90785Interactive complexity (Use in conjunction with codes for diagnostic psychiatric evaluation [90791, 90792], psychotherapy [90832, 90834, 90837], psychotherapy when performed with an evaluation and management service [90833, 90836, 90838, 99201-99255, 99304-99337, 99341-99350], and group psychotherapy [90853])
  • Refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients. Typical encounters include:
                   -   Patients who have other individuals legally responsible for their care
                   -   Patients who request others to be present or involved in their care such as translators, interpreters or additional family members
                   -   Patients who require the involvement of other third parties such as child welfare agencies, schools or probation officers
​90846Family psychotherapy (without patient present)
​90847Family psychotherapy (conjoint psychotherapy) (with patient present)
90849Multiple-family group psychotherapy
90853Group psychotherapy (other than of a multiple family group)
  • For interactive group psychotherapy use code 90785 in conjunction with code 90853
Other Psychiatric Services/Procedures
 
+90863Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (Use in conjunction with 90832, 90834, 90837)
  • For pharmacologic management with psychotherapy services performed by a physician or other qualified health care professional who may report E/M codes, use the appropriate E/M codes 99201-99255, 99281-99285, 99304-99337, 99341-99350 and the appropriate psychotherapy with E/M service 90833, 90836,90838).
  • Note code 90862 was deleted.
​90885Psychiatric evaluation of hospital records, other psychiatric reports, and psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes
​90887Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to family or other responsible persons, or advising them how to assist patient
​90889Preparation of reports on patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers
 
Screening & Testing
 
​96101Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
96102Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
​96103Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorshach, WAIS), administered by a computer, with qualified health care professional interpretation and report
​96105Assessment of aphasia (includes assessment of expressive and receptive speech and  language function, language comprehension, speech production ability, reading, spelling, writing, e.g., Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
​96110Developmental screening with scoring and documentation (eg, Developmental Screening Test II, Early Language Milestone Screen), per standardized instrument
​96127​Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
 
Non-Physician Provider (NPP) Services
 
​99490Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
  • multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
  • chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
  • comprehensive care plan established, implemented, revised, or monitored.
Chronic care management services are provided when medical and/or psychosocial needs of the patient require establishing, implementing, revising, or monitoring the care plan. If 20 minutes are not met within a calendar month, you do not report chronic care management. Refer to CPT for more information. ​
​99366Medical team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or family, 30 minutes or more, participation by a nonphysician qualified healthcare professional
​99368Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more, participation by a nonphysician qualified healthcare professional
​96150Health and behavior assessment performed by nonphysician provider (health-focused clinical interviews, behavior observations) to identify psychological, behavioral, emotional, cognitive or social factors important to management of physical health problems, 15 min., initial assessment 
​96151​re-assessment
96152Health and behavior intervention performed by nonphysician provider to improve patient’s health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems), individual, 15 min.
96153​group (2 or more patients)
​96154​family (with the patient present)
​96155​family (without the patient present)
 
Non-Face-to-Face Services: NPP
 
98966Telephone assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967​11-20 minutes of medical discussion
​98968​21-20 minutes of medical discussion 
​98969Online assessment and management service provided by a qualified nonphysician healthcare professional to an established patient, or guardian, not originating from a related assessment and management service provided within the previous seven days nor using the internet or similar electronic communications network
 
Miscellaneous Services
 
​99071Educational supplies, such as books, tapes or pamphlets, provided by the physician for the patient’s education at cost to the physician
 

 International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) Codes
  • Use as many diagnosis codes that apply to document the patient's complexity and report the patient,s symptoms and/or adverse environmental circumstances.
  • Once a definitive diagnosis is established, report the appropriate definitive diagnosis code(s) as the primary code, plus any other symptoms that the patient is exhibiting as secondary diagnoses that are not part of the usual disease course or are considered incidental.
  • ICD-10-CM codes are only valid on or after October 1, 2014.

Trauma- and Stressor- Related Disorders 

F43.10Post-traumatic stress disorder, unspecified
F43.11​Post-traumatic stress disorder, acute
​F43.12Post-traumatic stress disorder, acute
F43.21Adjustment disorder with depressed mood
​F43.22​Adjustment disorder with anxiety
​F43.23​Adjustment disorder with mixed anxiety and depressed mood
​F43.25​Adjustment diisorder with mixed disturbance of emotions and conduct
​F23.29​Adjustment disorder with other symptoms
​F43.0​Acute stress reaction
​F43.8​Other reactions to severe stress
​F43.9​Reaction to severe stress, unspecified
  
Dissociative Disorders 
F44.0      Dissociative amnesia 
F44.1      Dissociative fugue 
F44.2      Dissociative stupor 
F44.4      Conversion disorder with motor symptom or deficit 
F44.5      Conversion disorder with seizures or convulsions 
F44.6      Conversion disorder with sensory symptom or deficit 
F44.7      Conversion disorder with mixed symptom presentation 
F44.81    Dissociative identity disorder 
F44.89    Other dissociative and conversion disorders 
F44.9      Dissociative and conversion disorder, unspecified 
Behavioral/Emotional Disorders 
F90.0     Attention-deficit hyperactivity disorder, predominantly inattentive type 
F90.1     Attention-deficit hyperactivity disorder, predominantly hyperactive type 
F90.8     Attention-deficit hyperactivity disorder, other type 
F90.9     Attention-deficit hyperactivity disorder, unspecified type 
F91.1     Conduct disorder, childhood-onset type 
F91.2     Conduct disorder, adolescent-onset type 
F91.3     Oppositional defiant disorder 
F91.9     Conduct disorder, unspecified 
F93.0     Separation anxiety disorder 
F93.8     Other childhood emotional disorders (relationship problems) 
F93.9     Childhood emotional disorder, unspecified 
F94.9     Childhood disorder of social functioning, unspecified 
Depressive Disorders 
F32.0     Major depressive disorder, single episode, mild 
F32.1     Major depressive disorder, single episode, moderate 
F32.2     Major depressive disorder, single episode, severe without psychotic features 
F32.3     Major depressive disorder, single episode, severe with psychotic features 
F32.4     Major depressive disorder, single episode, in partial remission 
F32.5     Major depressive disorder, single episode, in full remission 
F32.8     Other depressive episodes (eg, atypical depression, post-schizophrenic depression) 
F32.9     Major depressive disorder, single episode, unspecified 
F33.0     Major depressive disorder, recurrent, mild 
F33.1     Major depressive disorder, recurrent, moderate 
F33.2     Major depressive disorder, recurrent severe without psychotic features 
F33.3     Major depressive disorder, recurrent, severe with psychotic symptoms 
F33.40   Major depressive disorder, recurrent, in remission, unspecified 
F33.41   Major depressive disorder, recurrent, in partial remission 
F33.42   Major depressive disorder, recurrent, in full remission 
F33.8     Other recurrent depressive disorders 
F33.9     Major depressive disorder, recurrent, unspecified 
F34.1     Dysthymic disorder (depressive personality disorder, dysthymia neurotic depression) 
Anxiety Related Disorders 
F40.00     Agoraphobia, unspecified 
F40.01     Agoraphobia with panic disorder 
F40.02     Agoraphobia without panic disorder 
F40.10     Social phobia, unspecified 
F40.11     Social phobia, generalized 
F40.8       Phobic anxiety disorders, other (phobic anxiety disorder of childhood) 
F40.9       Phobic anxiety disorder, unspecified 
F41.0       Panic disorder [episodic paroxysmal anxiety] without agoraphobia (panic attack) 
F41.1       Generalized anxiety disorder 
F41.9       Anxiety disorder, unspecified 
F93.0       Separation anxiety disorder of childhood 
Feeding and Eating Disorders/Elimination Disorders 
F50.8      Eating disorders, other (psychogenic vomiting) 
F50.9      Eating disorder, unspecified 
F98.0      Enuresis not due to a substance or known physiological condition 
F98.1      Encopresis not due to a substance or known physiological condition 
F98.3      Pica (infancy or childhood) 
F63.9      Impulse disorder, unspecified 
Neurodevelopmental Disorders 
F70       Mild intellectual disabilities 
F71       Moderate intellectual disabilities 
F72       Severe intellectual disabilities 
F73       Profound intellectual disabilities 
F79       Unspecified intellectual disabilities 
F80.4    Speech and language developmental delay due to hearing loss (code also hearing loss) 
F80.89  Other developmental disorders of speech and language 
F80.9    Developmental disorder of speech and language, unspecified 
Obsessive-Compulsive and Related Disorders 
F60.5      Obsessive-compulsive personality disorder 
F63.3      Trichotillomania/hair plucking 
F63.9       Impulse disorder, unspecified 
F98.8       Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence (nail-biting, nose-picking, thumb-sucking) 
Sleep Disorders 
F51.01       Primary insomnia 
F51.02       Adjustment insomnia 
F51.03       Paradoxical insomnia 
F51.04       Psychophysiologic insomnia 
F51.3         Sleepwalking [somnambulism] 
F51.4         Sleep terrors [night terrors] 
F51.8         Other sleep disorders not due to a substance or known physiological condition 
F51.9         Sleep disorder not due to a substance or known physiological condition, unspecified
 
Substance-Related and Addictive Disorders:
 
If a provider documents multiple patterns of use, only one should be reported. Use the following hierarchy:
                                  use--abuse--dependence (eg, if use and dependence are documented, only code for dependence).
When a minus symbol (-) is included in codes F10-F17, a last digit is required. Be sure to include the last digit from the following list:
0 anxiety disorder 
2 sleep disorder 
8 other disorder 
9 unspecified disorder
 
Alcohol 
F10.10Alcohol abuse, uncomplicated
F10.14Alcohol abuse with alcohol-induced mood disorder
​F10.159​Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.18-​Alochol abuse with alcohol-induced
​F10.19Alcohol abuse with unspecified alcohol-induced disorder
F10.20Alcohol dependence, uncomplicated
F10.21​Alcohol dependence, in remission
​F10.24Alcohol dependence with alcohol-induced mood disorder
F10.259Alcohol dependence with alcohol-induced psychotic disorder, unspecified
​F10.28-Alcohol dependence with alcohol-included
F10.29Alcohol dependence with unspecified alcohol-induced disorder
F10.94Alcohol use, unspecified with alcohol-induced mood disorder
F10.959​Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified
F10.98-Alcohol use, unspecified with alcohol-induced
​F10.99Alcohol use, unspecified with unspecified alcohol-induced disorder
 
Cannabis 
F12.10Cannabis abuse, uncomplicated
F12.18-Cannabis abuse with cannabis-included
​F12.19​Cannabis abuse with unspecified cannabis-included disorder
F12.20​Cannabis dependence, uncomplicated
​F12.21Cannabis dependence, in remission
F12.28-Cannabis dependence with cannabis-included
F12.29​Cannabis dependence with unspecified cannabis-induced disorder
​F12.90Cannabis use, unspecified, uncomplicated
F12.98-Cannabis use, unspecified with
​F12.99Cannabis use, unspecified with unspecified cannabis-induced disorder
Sedative
F13.10

Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.129Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified
F12.14​Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-included mood disorder
F13.18-Sedative, hypnotic or anxiolytic abuse with sedative. hyponotic or anxiolytic-included
​F13.21Sedative, hypnotic or anxiolytic dependence, in remission
F13.90Sedative, hypnotic or anxiolytic use, unspecified, uncomplicated
F13.94​Sedative, hypnotic or anxiolytic use with sedative, hypnotic or anxiolytic-included mood disorder
F13.98-Sedative, hypnotic or anxiolytic use with sedative. hyponotic or anxiolytic-included
​F13.99Sedative, hypnotic or anxiolytic use, unspecified with unspecific sedative, hyponotic or anxiolytic-induced disorder
 
Stimulants (eg, Caffeine, Amphetamines) 
F15.10Other stimulant (amphetamine-related disorders or caffine) abuse, uncomplicated
F15.14Other stimulant (amphetamine-related disorders or caffine) abuse with stimulant-induced mood disorder
​F15.18-​Other stimulant (amphetamine-related disorders or caffine) abuse with stimulant-induced
F15.19​Other stimulant (amphetamine-related disorders or caffine) abuse with unspecified stimulant included disorder
​F15.20Other stimulant (amphetamine-related disorders or caffine) dependence, uncomplicated
F15.21Other stimulant (amphetamine-related disorders or caffine) dependence, in remissioin
F15.24​Other stimulant (amphetamine-related disorders or caffine) dependence with stimulant-induced mood disorder
​F15.28-Other stimulant (amphetamine-related disorders or caffine) dependence with stimulated-induced
F15.29Other stimulant (amphetamine-related disorders or caffine) dependence with unspecified stimulant-induced disorder
​F15.90Other stimulant (amphetamine-related disorders or caffine) use, unspecified, uncomplicated
F15.94Other stimulant (amphetamine-related disorders or caffine) use, unspecified with stimulant-induced mood disorder
F15.98-Other stimulant (amphetamine-related disorders or caffine) use, unspecified with stimulant-induced
F15.99Other stimulant (amphetamine-related disorders or caffine) use, unspecified with unspecified stimulant-induced disorder
 
Nicotine (eg, Cigarettes) 
F17.200Nicotine dependence, unspecified, uncomplicated
F17.201Nicotine dependence, unspecified, in remission
​F17.203​Nicotine dependence unspecified, with withdrawal
F17.20-​Nicotine dependence, unspecified, with
​F17.210Nicotine dependence, cigarattes, uncomplicated
F17.211Nicotine dependence, cigarettes, in remission
F17.213​Nicotine dependence, cigarettes, with withdrawal
​F17.218-Nicotine dependence, cigarettes, with
 
Other
 
​F07.89​Other personality and behavioral disorders due to known physiological condition
​F07.9​Unspecified personality and behavioural disorder due to known physiological condition
F30.8Other manic episodes
F39Mood (affective) disorder, unspecified
F45.41Pain disorder exclusively related to psychological factors
F45.42Pain disorder with related psychological factor (code also associated acute or chronic pain (G89.-))
​F48.1​Depersonalization-derealization syndrome
​F48.8​Other specified nonpsychotic mental disorders
F48.9​Nonpsychotic mental disorder, unspecified
​F68.11​Factitious disorder with predominantly psychological signs and symptoms
F68.12​​Factitious disorder with predominantly physical signs and symptoms
F68.13Factitious disorder with combined psychological and physical signs and symptoms
 
Symptoms, Signs, and Ill-defined Conditions
 
    Use these codes in absence of a definitive mental diagnosis or when the sign or symptom is not part of the disease course or considered incidential.
 
G44.201​Tension-type headche, unspecified, intractable
G47.9Sleep disorder, unspecified
N39.44​Nocturnal enuresis
​R06.02Shortness of breath​
​R06.4Hyperventilation​
​R07.9Chest pain, unspecified​
​R10.0Acute abdomen pain
​R10.84Generalized abdnominal pain​
​R11.0Nausea​
R11.11Vomiting without nausea
R11.2Nausea with vomiting, unspecified
R19.8Other specified symptoms and signs involving the digestive system and abdomen
R42           Dizziness
R45.0        Nervousness
R45.83      Excerssive crying of child, adolescent or adult
R45.89      Other sympotoms and signs involving emotional stste
R47.89      Other speech disturbances
R47.9        Unspecified speech disturbances
R51           Headache
R53.81     other malaise
R53.82     Chronic fatigue, unspecified
R53.83     Other fatigue
R63.3       Feeding difficulties
R63.4       Abnormal weight loss
R63.5       Abnormal weight gain
R68.89     Other general symptoms and signs
 
Z Codes
 
Z codes represent for encounters. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury, or external cause classifiable to categories A00-Y89 are recorder as 'diagnoses' or 'problems'. This can arise in 2 main ways.
(a) When a person who may or may not be sick encounters the health service for some specific purpose, such as to receive limited care or service
      for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunication), or to discuss a problem is in itself not a
      disease or injury.
(b) When some circumstance or problem is present which influences the person,s health status but is not in itself a current illness or injury.    
 
​Z13.4Encounter fo screening for certain developmental disorders in childhood (not for routine screen)​
Z13.89Encounter for screening for other disorder (anxiety, depression)
Z59.5Extreme poverty
Z59.6​Low income
Z59.7Insufficient social insurance and welfare support
Z59.8Other problems related to housing and economic circumstances
​Z60.3​Acculturation difficulty
​Z60.4​Social exclusion and rejection
​Z60.5​Target of (perceived) adverse discrimination and persecution
Z60.9Problems related to social environment, unspecified
Z62.21Foster care status (child welfare)
Z62.810​Personal history of physical and sexual abuse in childhood
​Z62.811Personal history of psychological abuse in childhood​
​Z62.812​Personal history of neglect in childhood
Z62.819Personal history of unspecified abuse in childhood
Z63.4​Disappearance and death of family members ( *Bereavement)​
Z63.72Alcoholism and drug addiction in family
Z63.8Other specified problems related to primary support group
Z65.3Problems related to legal circumstances
​Z69.010​Encounter for mental health services for victim of parental child abuse
​Z69.020​Encounter for mental health services fo rvictim of parental child abuse
Z71.89Counseling, other specified
Z71.9Counseling, unspecified
Z72.0​Tobacco use
​Z77.011​Contact with and (suspected) exposure to lead
​Z81.0​Family history of intellectual disabilities (conditions classifiable to F70-F79)
​Z81.8​Family history of other mental and behavioral disorders
​Z83.2​Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (anemia)
​Z86.2​Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
​Z86.39​Personal history of other mental and behavioral disorders
Z86.59 Z86.69Personal history of other diseases of the nervous system and sense organs
Personal history of other diseases of the nervous system and sense organs
​Z87.09​Personal history of other diseases of the respiratory system
​Z87.19​Personal history of other diseases of the digestive system
Z87.798Personal history of other (corrected) congenital malformations 
​Z87.81​Personal history of (healed) traumatic fracture
​Z87.820​Personal history of traumatic brain injury
​Z87.828​Personal history of other (healed) physical injury and trauma
Z88.9​Allergy status to unspecified drugs, medicaments and biological substances status
​Z91.09Other allergy status, other than to drugs and biological substances​
Z91.14Patient's other noncompliances with medication regimen
Z91.19Patient's noncompliances with other medical treatment and regimen

 


+ Codes are add‐on codes, meaning they are reported separately in addition to the appropriate code for the service provided
- Indicated the ICD-10-CM code requires another character 
Current Procedural Terminology® 2015 American Medical Association. All Rights Reserved.  

 

 

 
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