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Code: Z51.81
Encounter for therapeutic drug level monitoring
Code also any long-term (current) drug therapy (Z79.-)
Excludes 1: encounter for blood-drug test for administrative or medicolegal reasons (Z02.83)
Parent Code Notes: Z51.8
Excludes1: holiday relief care (Z75.5)
Parent Code Notes: Z51
Code also: condition requiring care
Excludes1: follow-up examination after treatment (Z08-Z09)

Category Notes
Encounters for other specific health care (Z40-Z53)
Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state
Excludes 2: follow-up examination for medical surveillance after treatment (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.

JJOHN0312

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I just found out yesterday from a compliance audit that we are not suppose to use a diagnosis code (such as Z51.81) for reporting. We are suppose to use a "diagnostic statement" from the physician order. I guess there has been a coding clinic out there for a while?? And new guidance this year?? Any thoughts on this?

Josie
 

CodingKing

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I don't know about the coding clinic but the whole Z51 range has a Code Also condition requiring care. So there should be a condition, the encounter for therapeutic drug level monitoring code and a Long term use of drug code.
 

JJOHN0312

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Z51.81

Yes, but that wasn't the point. My point is, we cannot use a diagnosis code from an order for reporting on a claim, regardless how many diagnosis codes that are listed. What must be on the order: is a diagnostic statement from the physician. Anyone else have to change there processes because of this?

Thank you!

Josie Johnson, COC, CPC, CPMA
 

JJOHN0312

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Z51.81

Also, I believe you can use Z51.81 with Z79.01 and not code the condition. Please see Chapter 21, c.,7 for aftercare codes. And I believe there is also a guideline for Z79.--.
 
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Coding Clinic - Diagnostic statement

I just found out yesterday from a compliance audit that we are not suppose to use a diagnosis code (such as Z51.81) for reporting. We are suppose to use a "diagnostic statement" from the physician order. I guess there has been a coding clinic out there for a while?? And new guidance this year?? Any thoughts on this?

Josie

The Coding Clinic guidance from the first quarter of 2012 was in response to a question regarding physicians assigning only a diagnosis code in the electronic record vs. stating a diagnosis and then assigning/selecting a code. In the physician practice, the diagnostic statement is often labeled the assessment and should state the conditions addressed with more specificity than is typically captured in codes (e.g., what drug was monitored). Consider that many diagnosis codes have multiple inclusion notes (e.g., J02.9 could indicate acute sore throat, gangrenous pharyngitis, or ulcerative pharyngitis) which while fine for classification may not be specific enough for patient care and/or showing medical necessity of services rendered/ordered. If there is no diagnostic statement, the record with only codes to represent the diagnoses would not likely meet the regulatory standards for documentation.

I have not seen additional guidance but my access to Coding Clinic is limited to what will come up in a search by term and often doesn't provide the desired result. Perhaps someone else can provide more information.

Medicare does require that the laboratory be prepared to offer documentation supporting the medical necessity of the tests - https://www.cms.gov/Outreach-and-Ed...Downloads/LabServices-ICN909221-Text-Only.pdf

Cindy
 
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grothrock

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This was the question and answer asked in the coding clinic 4th quarter 2015

Question:

Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10-CM diagnosis code instead of a descriptive diagnostic statement. We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number?

Answer:


Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-10- CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.


While we're aware that some payers may allow submission of code numbers on lab orders, Coding Clinic recommends that physicians provide narrative diagnoses/signs/symptoms as the reason for ordering the test.
 

kbarbag

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This was the question and answer asked in the coding clinic 4th quarter 2015

Question:

Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10-CM diagnosis code instead of a descriptive diagnostic statement. We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number?

Answer:


Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-10- CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.


While we're aware that some payers may allow submission of code numbers on lab orders, Coding Clinic recommends that physicians provide narrative diagnoses/signs/symptoms as the reason for ordering the test.

Do you know who/what the regulatory and accreditations directives are from?
Kathy
 
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