Chapter 21 of ICD-10-CM is titled "Factors Influencing Health Status and Contact with Health Services". They cover codes in the categories from Z00 to Z99. This chapter is used for encounters with health care providers where the patients have no current illnesses or injury. For example, a patient may present at a clinic because they were around a bunch of sick people, and they want to make sure they did not catch the disease. The Z20 category is contact with and (suspected) exposure to communicable diseases. A code from this category would show that the patient is not ill, but clearly has a good reason to be in the doctor's office.
These codes can be used in any healthcare setting, and they may be the first listed diagnosis, or a secondary code, depending on the circumstances. Z codes do not replace procedure codes. For example, the appropriate CPT code would still need to be reported along with Z23 Encounter for immunization.
Z codes are broken into the following groups:
According to guideline 1;C.21.c.16 there are 20 Z-codes that 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.
92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient
You would use a Z-Code for the eye exam:
Z01.00 Encounter for examination of eyes and vision without abnormal findings. This code would be appropriate for refractive disorders.
Z01.01 Encounter for examination of eyes and vision with abnormal findings. An additional code would be reported to identify the abnormal finding. This is in addition to refractive disorders.
A patient was seen for a routine physical examination, 99395 Periodic comprehensive preventive medicine reevaluation and management. An acceptable diagnosis code to use would be:
Z00.00 Encounter for general adult medical examination without abnormal findings. This patient might have come in for an annual wellness exam.
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