Health status condition documentation requirements

Page last updated on: 6/17/25

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.XX, F10.XXX

Opioid related disorders - use/abuse/dependence

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

Z99.1X

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