Wiki Using Z code which is not documented

[Blackhorse]

I tried to use Z51.81for drug testing patients for our lab. However my manager says that the code is not documented on the requisition/order, or progress note, we cannot use this code. Provider use F41.9 which will not get paid for 80307. I don't think the Z codes need to be documented by providers and we can still bill it. Am I right?

 

[iowagirl77]

Your manager is correct- you cannot make the assumption; you need the diagnosis to be documented. If the documentation doesn't support a medically necessary diagnosis, you may query the provider, but you cannot guess at what they intended it to be done for.

 

[TThivierge]

Hi Blackhorse,
Your manager s right it must be documented on the medical record and relate to current reason for treatment. I believe you are thinking if the medical HO of past illness is listed on current med record for patient you can add that to claim. Dx Z51 as 2nd dx code can be the best code to use for reason on testing for drug use. I d use the reason F41 and dx Z51 or Z86.59 if appropriate. Past HO Z86.59 for mental illness does include past substance abuse disorders too. Have you ever used dx Z01.89 as first listed dx code for CPT 80370? Also if pt get blood testing checking drug use you can use dx R87 and dx Z02.83 if blood test results drug in patients' system. Also check out dx R82.89 if urine results show drug use. I'd add the drug if shown positive in results F10 Alcohol, F11 Opioids, F14 Cocaine F12 Cannabis or F19 Differ psychoactive substance drugs or whatever????
Well I hope helped you!
Lady T

 

[thomas7331]

I tried to use Z51.81for drug testing patients for our lab. However my manager says that the code is not documented on the requisition/order, or progress note, we cannot use this code. Provider use F41.9 which will not get paid for 80307. I don't think the Z codes need to be documented by providers and we can still bill it. Am I right?

The ICD-10 guidelines, in section I.B.14, gives a limited list of the types of codes that may be documented by clinicians other than the provider. This includes some of the 'Z codes', such as BMI and SDOH codes. Those must still be documented in the record, but can be documented by qualified individuals or than the physician or NPP. But if not documented at all, then no, the code can't be assigned.

 

[Blackhorse]

Thank you for all of the above replies Our facility providers normally use the Dx on DSM 5 and have no idea how to use Z codes to get paid. I plan to set up a meeting with the facility to discuss how to document the Z codes.