ICD 10 codes used for Encounter for observation and Evaluation
Diagnosis codes are little tough to code when there is no specific condition given to code in medical report. Till now we have come across all the ICD 10 codes, which are used as either primary or secondary diagnosis.
But, today we will learn to code for encounter of observation and evaluation. Before moving ahead I would suggest you get some knowledge about ICD 10 codes in the below links.
Difference between Aftercare and follow-up ICD 10 codes
Primary and Secondary ICD 10 codes for Neoplasm
Common mistakes with ICD 10 codes
Use of Z codes as secondary diagnosis
When to use initial, subsequent and Sequel Injury ICD 10 codes
When to use Z03, Z04 and Z05 category
Z03 category is used or suspected diseases or rule out condition. In many cases, the physician suspects a presence of a disease and hence under observation evaluates the patient. For such encounter reports, when the suspected disease is not found in the final medical report, we have to report the Z03 category codes.
For example, sometimes a condition is rule out or ruled out, in such cases we have to use the ruled out condition as primary diagnosis if present, otherwise we have to assign ICD 10 code Z03.89.
Z03.89 Encounter for medical observation for suspected diseases and conditions ruled out.
On the contrary, if the suspected disease or condition is not present, then you can code any related signs or symptom related to suspected disease, documented in the report. Here, you cannot use the Z03.89 as primary diagnoses.
The observation codes are not used if an injury or illness, or any signs or symptoms related to the suspected condition, are present.
The encounter for observation and evaluation code from Z03 or Z04 category should be used only where there is no signs and symptoms present and the suspected condition is absent.
Use codes from category Z05 for observation and evaluation of a newborn within the neonatal period for suspected disease or condition, ruled out.
Do remember the codes from Category Z03-Z04 should always be used as primary diagnosis and not secondary diagnosis.
Read also: ICD 10 coding update for Z3A category for Medical coders
Examples for ICD 10 category Z03, Z04 and Z05
A law representative refers a patient for evaluation of a suspected mental disorder. The condition was absent in the patient. Hence, code Z04.6, Encounter for general psychiatric examination, requested by authority is assigned as the primary diagnosis.
A patient has a strong family history of colon cancer, the patient is admitted for the evaluation of suspected malignancy. The report is assigned with Code Z03.89, Encounter for observation for other suspected diseases and conditions ruled out, with an additional code of Z80.0, Family history of malignant neoplasm of digestive organs.
An adult patient is seen in the emergency department because of alleged rape. Observation and examination reveal no physical findings, such as hemorrhage or laceration. Code Z04.41, Encounter for examination and observation following alleged adult rape, is assigned as the principal diagnosis.