Wiki Code Z91.19

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B
Code: Z91.19
Patient's noncompliance with other medical treatment and regimen
Nonadherence to medical treatment
Parent Code Notes: Z91
Excludes2: contact with and (suspected) exposures hazardous to health (Z77.-)
exposure to pollution and other problems related to physical environment (Z77.1-)
female genital mutilation status (N90.81-)
personal history of physical injury and trauma (Z87.81, Z87.82-)
occupational exposure to risk factors (Z57.-)

Category Notes
Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)
Code also any follow-up examination (Z08-Z09)

Coding Guidelines
Factors influencing health status and contact with health services (Z00-Z99)
Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
(a) When a person who may or may not be sick encounters the health services 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 (immunization), or to discuss a problem which 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.

CodingKing

True Blue
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No it cannot be listed as first dx. How could a patient be non-compliant with other medical treatment and regimen but not have a condition being treated?
 

nbackus

New
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Theresa, NY
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Z91.19

The patient is being dismissed from the practice and the provider saw them (ROS and Exam performed)and gave them 30 days of medication.

The patient had just left a Rehab Facility AMA so he had no medications.

According to the provider she did not counsel the patient and does not want to add the chronic conditions to the note as she has no medical necessity documentation.

What would you suggest?

Thank you
 

mitchellde

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Columbia, MO
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You need a consequence. So if the patient did not follow thru with treatment, what was the result? Otherwise there is no reason to report the noncompliance. If there is nothing else documented then I would say it cannot be billed.
 
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