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Icd 10 for past history of needle stick?

P

PVAzCPC

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Provider documented only: "During her career, she has had needlestick injury. Unsure if she had had Hep B vaccine. Has not been tested for hepatitis C." Provider ordered labs, incl Hep B,C, RPR, and HIV.

No documentation that she'd ever actually been exposed to bodily fluids. Tatoos don't count as high-risk behavior. No other signs/symptoms, except fatigue.

Any ideas?

Thanks!
 
This sounds like information from the history and would not be the primary source of information for an ICD-10 code. What is documented as the reason for the visit, and what was the provider's assessment based on the outcome of the history and exam? Or if this is a preventive service being done based on the possible exposure to disease through the needle stick, you could use Z20.5 and Z20.6 for a 'suspected' exposure.
 
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