Question Z65.1 Imprisonment and other incarceration SDOH

[CourtneyAnn95]

If it is notated in the encounter that a patient has a History of prison / imprisonment / incarceration - is Z65.1(Imprisonment and other incarceration justified to use this?

Many times I see providers noting the general history / release in the HPI, but only document with Z11.59 (Encounter for screening for other viral diseases) as a dx to obtain an HCV lab draw. Medical wise, we know that incarceration increases SDOH risks & medical risks. I believe documenting this "history of" is important for the ongoing / new patient treatment.

I am hesitant to add Z65.1 to the encounter, as it is not clear enough to determine if the definition allows "history of" as applicable, OR if it is only valid for being currently incarcerated?

Thank you!

 

[jkyles]

Hi, unless there's some additional documentation I'd say no. Please refer to ICD-10-CM guideline I.C.21.c.17

For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living.

When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2.

 

[rachaelwilleford]

I'd only utilize this if it affects decision for treatment or other medical decision making specific or there's other mention to the associated risk in specific relation to the encounter being reported.