ED Coding and Reimbursement Alert

Question: At the beginning of the J section in the ICD10-CM manual, there is a note to code also, “where applicable,” the smoking status of a patient. Does “where applicable” pertain to where the code also is noted in the tabular or if it pertains to where the provider notes a smoking status in a record?

Codify Subscriber

Answer: The “where applicable” note in the J section of the ICD-10-CM manual refers to the clinical encounter, not the code’s parenthetical notes in the tabular. These instructions simply are telling the coder to code the smoking status of the patient — if the provider documents as much. Specifically, ICD-10-CM instructs you code smoking status when the provider documents one or more of the following clinical encounters:

• “exposure to environmental tobacco smoke (Z77.22)
• “exposure to tobacco smoke in the perinatal period (P96.81)
• “history of tobacco dependence (Z87.891)
• “occupational exposure to environmental tobacco smoke (Z57.31)
• “tobacco dependence (F17.-)
• “tobacco use (Z72.0).”

If you have no documentation of smoking status, you need not report any codes for it.