What is the Diagnosis Code for Preventive Care?

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Preventive care intends to help patients by identifying potential health problems. As reporting only  meant for asymptomatic patients, which require comprehensive documentation. This article will  focus on the coding guidelines of the ICD-10 codes from Chapter 21 to describe the preventive care  services. Although the ICD-10 preventive codes are straightforward, yet encounter complications in  the combination of CPT/HCPCS and ICD-10 codes. 

Coding guidelines for Immunizations: 

Every billed service for preventive visits describes the reason with a CPT or HCPCS code. Codes  for any immunizations report under Z23 regardless of the number or type of vaccines. Therefore,  instead of individual diagnosis codes, the reporting is under multiple childhood immunizations. The  Z codes encounter for influenza are addressed under ICD-10. V04.81 for influenza immunization in  ICD-9 whereas, V06.6 for pneumonia and influenza if taken on the same date. For simplification,  ICD-10 recommends only Z23 irrespective of the type of vaccines or number documented.  According to the Z23 code set, a well-child visit coinciding with immunizations, in that case, a code  for routine health examination is reported first. 

Coding guidelines for Well-Child Examinations: 

Well-child examinations are similar to ICD-9 rules. Z code for health examination for a newborn  under eight days old is Z00.110. Health examination for newborn eight to twenty-eight days old,  report code Z00.111. Additionally, Z00.121 & Z00.129 code set for routine child health examination  with and w/o abnormal findings. Every billed service requires code for any abnormalities,  irrespective of additional reported service. 

Coding guidelines for Adult Annual Examinations: 

The reporting in the adult annual examinations is similar to the well-child exam, including any  abnormalities findings. For example: 

Z00.00 for general adult medical examination w/o abnormalities, 

Z00.01 for adult annual examinations with abnormalities, 

Z01.411 for gynecological examination (routine) (general) with bnormalities, Z01.419 for gynecological examination (routine) (general) without abnormalities 

For gynecological examination, there are additional codes needed for a screening vaginal Pap smear  is Z12.72. Screening for human papillomavirus is Z11.51, and if applicable, Z90.71 for the absence  of uterus. For outside gynecological examination, Z12.4 for Pap smear for malignant neoplasm of  the cervix. Otherwise, Z01.411 or Z01.419 as a part of the gynecological exam. 

Coding guidelines for Vision or hearing Examinations: 

Code set for eyes and vision examination also relies on the abnormal findings. For example: 

Z01.00 for eyes and vision examination w/o abnormalities, 

Z01.01 for eyes and vision examination with abnormal findings 

Your code selection for a routine examination of the ears and hearing is dependent on any abnormal  findings. ICD-10 codes are as follows: 

Z01.10 for the examination of the ears and hearing w/o abnormalities,

Z01.110 for hearing screening when the patient failed a hearing test. For instance, a child suspects  having hearing problems. Whereas after the diagnosis not result so. In that case, an appropriate  diagnosis code would suffice, 

Z01.118 for screening ears and hearing with other abnormalities 

Coding guidelines for Preventive Screenings: 

ICD-10 codes for preventive screenings are pretty straightforward. For instance: 

Z13.6 code for cardiovascular disorders,  

Z12.11 code for malignant neoplasm of colon, 

Z13.89 code for other disorders like depression, 

Z13.1 code for diabetes mellitus, 

Z11.4 code for HIV (human immunodeficiency virus), 

Z13.88 code for disorder due to exposure to lead or other contaminants, 

Z13.220 code for lipoid disorders, 

Z68.30-Z68.45 codes for IBT (obesity intensive behavioral therapy), 

Z13.820 code for osteoporosis, 

Z12.5 code for prostate cancer, 

Z11.1 codes for respiratory tuberculosis, 

Z11.3, Z72.89, Z11.59, and Z11.8 codes for sexually transmitted infection (STI)