Wiki Suspected Foreign Body in ER

[staceybu]

I have an encounter where a parent brought their child to the ER because they were worried they had swallowed a battery. The imaging showed no foreign body and the doctor's final diagnosis was worried well. The child had no symptoms.

Can I code Z03.821 Encounter for observation for suspected ingested foreign body ruled out as the principal? I was taught you can't use encounter codes in the ER you should instead code signs and symptoms but there really aren't any.

I was hoping maybe someone else had run into this and would have some guidance.

Thanks!

 

[mikhaila]

I have an encounter where a parent brought their child to the ER because they were worried they had swallowed a battery. The imaging showed no foreign body and the doctor's final diagnosis was worried well. The child had no symptoms.

Can I code Z03.821 Encounter for observation for suspected ingested foreign body ruled out as the principal? I was taught you can't use encounter codes in the ER you should instead code signs and symptoms but there really aren't any.

I was hoping maybe someone else had run into this and would have some guidance.

Thanks!

Hello,

According to the guidelines shown below it is okay to code Z03.821. The child had no symptoms of the suspected condition and the doctor ruled the suspected condition out.
If the child displayed symptoms of the suspected condition then you would have had to code signs and symptoms unless of course, the provider gave a definitive diagnosis.



Section: 1;C.21.c.16
16) Z Codes That May Only be Principal/First-Listed Diagnosis

The following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined:

Z00 Encounter for general examination without complaint, suspected or reported diagnosis

Except: Z00.6

Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

Z02 Encounter for administrative examination

Z03 Encounter for medical observation for suspected diseases and conditions ruled out

Z04 Encounter for examination and observation for other reasons

2024 ICD-10-CM Guidelines​

Level

Guidelines

Z03

Section: 1;C.21.c.6 6) Observation There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.

 

[staceybu]

Thank you for your help!!