Wiki Counseling Z Codes - What am I looking for?

[AprilSueMadison]

What kind of documentation would support using the Z counseling codes as a PCP? Such as Z71.7, HIV counseling or Z71.5X, drug abuse counseling. The provider notes something along the lines of the reason for visit being an HIV test, we do the test and it comes back negative, and then the he notes that he "discussed transmission, prevention, timeframe that it could take to be positive."

Literally, the section in quotes is all I have to work with. I'd love to have some more information from someone who has more experience with these codes.

 

[rvalente]

Hi April Sue,
the criteria I look for when capturing counseling codes is of course, how it is documented. I only capture codes that state "counseling" specifically. To me "discussed" is probably the same as "counseled" but that is not what the documentation states so I wouldn't code it as such.

This is an opportunity to educate your clinicians in proper documentation in order to capture these codes.

Our guidelines state:

Counseling Counseling Z codes are used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. They are not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.

So I take that statement to be, if you are doing an HIV screening, the counseling component would not be captured separately.

Hope that helps