Health status condition documentation requirements
Certain codes are designated as status codes to identify that a patient is the carrier of a disease with:
- No current symptoms
- Lingering effects of a past condition or past treatment
- Distinct from history codes, which indicate that a patient no longer has a condition
- Identifying the patient's health status may affect treatment or outcome of another condition
The Importance of Z Codes
Z codes (other reasons for healthcare encounters) may be used to further explain reasons for a healthcare service. Z codes can be used in any healthcare setting. The ICD-10-CM Guidelines for Coding and Reporting, instruct you to code for all coexisting comorbidities, especially those part of medical decision-making (MDM). It’s important to review all 16 categories, including Contact/Exposure, History (of), and Status.
Requirements
All chronic and status conditions must be documented and reported at least once each year.
Examples of ICD-10 health status code use
Condition/Status | ICD-10 Health Status Code |
---|---|
Protein calorie malnutrition | E44.X, E46 |
Alcohol related disorders - use/ abuse/dependence | F10.XX, F10.XXX |
Opioid related disorders - use/abuse/dependence | F11.XX, F11.XXX |
Sedative, hypnotic, or anxiolytic related disorders | F13.X, F13.XX, F13.XXX |
Old myocardial infarction (MI) | I25.2 |
Asymptomatic for HIV infection | Z21 |
Organ or tissue replaced by transplant | Z94.X |
Artificial opening (tracheostomy, gastrostomy, colostomy, ileostomy) | Z93.X |
Renal dialysis | Z99.2 |
Dependence on respirator | Z99.1X |
Acquired absence of limb (toe, foot, ankle included) | Z89.X, Z89.XX, Z89.XXX |
Attention to artificial openings | Z43.X |
Long-term (current) insulin use | Z79.4 |