Health status condition documentation requirements

Certain codes are designated as status codes to identify that a patient is the carrier of a disease with:

  • No current symptoms
  • Lingering effects of a past condition or past treatment
  • Distinct from history codes, which indicate that a patient no longer has a condition
  • Identifying the patient's health status may affect treatment or outcome of another condition

The Importance of Z Codes

Z codes (other reasons for healthcare encounters) may be used  to further explain reasons for a healthcare service. Z codes can be used in any healthcare setting. The ICD-10-CM Guidelines for Coding and Reporting, instruct you to code for all coexisting comorbidities, especially those part of medical decision-making (MDM). It’s important to review all 16 categories, including Contact/Exposure, History (of), and Status.

Requirements

All chronic and status conditions must be documented and reported at least once each year.

Examples of ICD-10 health status code use

Condition/Status ICD-10 Health Status Code
Protein calorie malnutrition E44.X, E46
Alcohol related disorders - use/ abuse/dependence F10.X, F10.XX, F10.XXX
Opioid related disorders - use/abuse/dependence F11.X, F11.XX, F11.XXX
Sedative, hypnotic, or anxiolytic related disorders F13.X, F13.XX, F13.XXX
Old myocardial infarction (MI) I25.2
Asymptomatic for HIV infection Z21
Organ or tissue replaced by transplant Z94.X
Artificial opening (tracheostomy, gastrostomy, colostomy, ileostomy) Z93.X
Renal dialysis Z99.2
Dependence on respirator Z99.1
Acquired absence of limb (toe, foot, ankle included) Z89.X, Z89.XX, Z89.XXX
Attention to artificial openings Z43.X
Long-term (current) insulin use Z79.4