Neurosurgery Coding Alert

Z codes can provide diagnostic information for non-acute conditions

Although you’ve been using ICD-10 for almost two years now, you may still be studying your diagnosis coding manual to elucidate the nuances of the new system. One such area that has many neurosurgery practices stymied is the use of “Z” codes, which describe “Factors influencing health status and contact with health services.”

If you think the Z codes don’t apply to your practice, you’re probably incorrect — read on to determine how these codes can help you collect.

If a Z Code Is the Best Option, Use It

Contrary to what some coders believe, you may — and on occasion should — report Z codes as primary diagnoses. “Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter,” the ICD-10 manual says. “Certain Z codes may only be used as a first-listed or principal diagnosis.”

Perhaps the most common instance when you should select a Z code as a primary diagnosis is for screening exams. These could include screenings for neoplasms (for instance, Z12.81, Encounter for screening for malignant neoplasm of oral cavity), as well as other diseases (Z13.850, Encounter for screening for traumatic brain injury).

Be  aware: A “screening” means that the surgeon performs an exam to determine the presence of a condition in the absence of any relevant signs or symptoms.

For instance:  If a patient presents with symptoms such as dizziness (R42) headaches (R51), and nausea (R11.0), the surgeon might want to examine the patient for a neoplasm of the brain. In this case, you should use the signs and symptoms to justify the exam rather than a screening code such as Z12.81. You’ll reserve the screening code for preventive situations.

Aftercare Provides More Z Code Opportunities

You might also use Z codes as primary diagnoses when the surgeon provides follow-up care for a patient with past injuries and/or treatment.

Example: A patient presents for aftercare to address the functionality of an implanted neuropacemaker. You’ll report Z45.42 (Encounter for adjustment and management of neuropacemaker [brain] [peripheral nerve] [spinal cord]) to describe the reason for the visit.

Example 2: Coders and physicians often make the mistake of overlooking Z codes for patients whose disease processes are no longer active, but this is another area where these codes are helpful. For instance, a female patient who has successfully undergone surgery for removal of a brain neoplasm visits the surgeon for evaluation of wound and neurological deficits.

In this case, rather than report an acute diagnosis of brain neoplasm (for instance, C71.1, Malignant neoplasm of frontal lobe) — which is inaccurate — you should select Z48.3 (Aftercare following surgery for neoplasm) to reflect that the checkup is for a condition that is no longer acute. “Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease,” according to ICD-10 guidelines.