ICD-10 is fast approaching!
Come October 1st the healthcare industry begins to use the new diagnosis coding regimen and with that transition the ambulance billing industry will face a new set of rules and billing guidelines to follow including the “Z” codes.
Reasons for Encounters…
The “Z” codes denote reasons for encounters. So, when the billing office uses this code, it is to be used along with a primary diagnosis code that describes the illness or injury. The “Z” code is secondary and falls within a broad category labeled “Factors Influencing Health Status and Contact with Health Services.”
The codes in this subset are to be used for the following…
- When a person who may or may not be sick encounters health service for some specific purpose.
- When some circumstance or problem is present which influences the person’s health status but is not in itself a current injury or illness.
Why “Z”?
So you say, “Why this discussion right now?”
The largest Medicare Administrative Contractor (MAC) in the United States is mandating the use of five “Z” codes is why.
While we have not heard of another MAC that will enact this requirement, it’s still good information to share with everyone in the blogosphere as the basic principles of medical necessity and reasonableness exist across all billing platforms, whether or not your EMS agency resides in the Jurisdictions where Novitas accepts claim processing responsibility.
Four Codes that Support Medical Necessity
First, take a minute to review the CMS definition of medical necessity of an ambulance patient. We’ve blogged on it in the past so hit the archives or simply check out the definition on the CMS website.
With the definition in mind, following are the codes with some brief comments on the expectations for documentation to support which code we will use to describe your EMS incident.
Z74.01- Bed Confinement Status
A patient is considered Bed Confined when he/she is…
- Unable to get up from bed without assistance –and-
- Unable to ambulate –and-
- Unable to sit in a chair or a wheelchair
You must document in the PCR specifically what you have assessed and learned from the patient and/or family that confines the patient to the bed at all times.
Z74.3- Need for Continuous Supervision
Your PCR must record the patient’s need for monitoring and you must be SPECIFIC about the monitoring provided. We anticipate that this code will fit particularly well in a 9-1-1 emergency transport billing scenario in many cases and the guidance provided by Novitas directs this code to be used for cardiac/hemodynamic monitoring that is requiredduring transport.
Be detailed and specific! It’s your burden to make the case in your PCR why the patient needed an ambulance and could not be safely transported by any other means from Point A to Point B in order to sustain life function.
Z78.1- Physical Restraint Status
EMS providers must always describe in great detail when a patient must be transported to maintain the safety of the patient and others surrounding the patient, including the ambulance crew. Billers will use this secondary code to denote those instances when the patient is a danger to himself/herself and others. This will involve patients who are known to be treated in a psychiatric situation requiring one-on-one monitoring by members of the ambulance crew for any type of reactive psychosis and/or are acting out exhibiting involuntary or voluntary movements.
Z99.89- Dependence on Other Enabling Machines or Devices
The key word here is “Dependence”. EMS providers will be documenting in great detail patients’ conditions requiring and the presence and active use of certain life-sustaining, enabling machines during the transport. The most notable for ambulance transports are C-Paps, Bi-Paps and ventilators among others.
One Code DOES NOT Support Medical Necessity
We close this discussion by revealing one code that DOES NOT support medical necessity.
Z76.89 will be required to explain an ambulance transport of a “Person Encountering Health Services in Other Specified Circumstances.” When your PCR documentation documents a patient who is transported by ambulance but did not require the services of the ambulance crew, then your billing office will be required to use this secondary code to report the scenario when billing to Novitas/Medicare Part B and will spark a denial for payment.
EMS providers must be truthful when documenting ambulance transport scenarios even if it means that the claim will be denied when the patient’s medical necessity cannot be established and the trip is considered to not be reasonable for payment from the Medicare Part B program.
Note
- Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories
ICD-10-CM Diagnosis Code A00
- 2016 2017 2018 2019 2020 2021 2022 Non-Billable/Non-Specific Code
- (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
- (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.
Codes
- Z00-Z13 Persons encountering health services for examinations
- Z14-Z15 Genetic carrier and genetic susceptibility to disease
- Z16-Z16 Resistance to antimicrobial drugs
- Z17-Z17 Estrogen receptor status
- Z18-Z18 Retained foreign body fragments
- Z19-Z19 Hormone sensitivity malignancy status
- Z20-Z29 Persons with potential health hazards related to communicable diseases
- Z30-Z39 Persons encountering health services in circumstances related to reproduction
- Z40-Z53 Encounters for other specific health care
- Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances
- Z66-Z66 Do not resuscitate status
- Z67-Z67 Blood type
- Z68-Z68 Body mass index (BMI)
- Z69-Z76 Persons encountering health services in other circumstances
- Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status
ICD-10-CM Range Z00-Z13
Persons encountering health services for examinations
Note
- Nonspecific abnormal findings disclosed at the time of these examinations are classified to categories R70-R94.
Type 1 Excludes
- examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)
- Z00 Encounter for general examination withou...
- Z01 Encounter for other special examination ...
- Z02 Encounter for administrative examination
- Z03 Encounter for medical observation for su...
- Z04 Encounter for examination and observatio...
- Z05 Encounter for observation and evaluation...
- Z08 Encounter for follow-up examination afte...
- Z09 Encounter for follow-up examination afte...
- Z11 Encounter for screening for infectious a...
- Z12 Encounter for screening for malignant ne...
- Z13 Encounter for screening for other diseas...
ICD-10-CM Range Z14-Z15
Genetic carrier and genetic susceptibility to disease- Z14 Genetic carrier
- Z15 Genetic susceptibility to disease
ICD-10-CM Range Z16-Z16
Resistance to antimicrobial drugs- Z16 Resistance to antimicrobial drugs
ICD-10-CM Range Z17-Z17
Estrogen receptor status- Z17 Estrogen receptor status
ICD-10-CM Range Z18-Z18
Retained foreign body fragments- Z18 Retained foreign body fragments
ICD-10-CM Range Z19-Z19
Hormone sensitivity malignancy status- Z19 Hormone sensitivity malignancy status
ICD-10-CM Range Z20-Z29
Persons with potential health hazards related to communicable diseases- Z20 Contact with and (suspected) exposure to...
- Z21 Asymptomatic human immunodeficiency viru...
- Z22 Carrier of infectious disease
- Z23 Encounter for immunization
- Z28 Immunization not carried out and underim...
- Z29 Encounter for other prophylactic measure...
ICD-10-CM Range Z30-Z39
Persons encountering health services in circumstances related to reproduction- Z30 Encounter for contraceptive management
- Z31 Encounter for procreative management
- Z32 Encounter for pregnancy test and childbi...
- Z33 Pregnant state
- Z34 Encounter for supervision of normal preg...
- Z36 Encounter for antenatal screening of mot...
- Z37 Outcome of delivery
- Z38 Liveborn infants according to place of b...
- Z39 Encounter for maternal postpartum care a...
- Z3A Weeks of gestation
ICD-10-CM Range Z40-Z53
Encounters for other specific health care
Applicable To
- Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state
Type 2 Excludes
- follow-up examination for medical surveillance after treatment (Z08-Z09)
- Z40 Encounter for prophylactic surgery
- Z41 Encounter for procedures for purposes ot...
- Z42 Encounter for plastic and reconstructive...
- Z43 Encounter for attention to artificial op...
- Z44 Encounter for fitting and adjustment of ...
- Z45 Encounter for adjustment and management ...
- Z46 Encounter for fitting and adjustment of ...
- Z47 Orthopedic aftercare
- Z48 Encounter for other postprocedural after...
- Z49 Encounter for care involving renal dialy...
- Z51 Encounter for other aftercare and medica...
- Z52 Donors of organs and tissues
- Z53 Persons encountering health services for...
ICD-10-CM Range Z55-Z65
Persons with potential health hazards related to socioeconomic and psychosocial circumstances- Z55 Problems related to education and litera...
- Z56 Problems related to employment and unemp...
- Z57 Occupational exposure to risk factors
- Z58 Problems related to physical environment
- Z59 Problems related to housing and economic...
- Z60 Problems related to social environment
- Z62 Problems related to upbringing
- Z63 Other problems related to primary suppor...
- Z64 Problems related to certain psychosocial...
- Z65 Problems related to other psychosocial c...
ICD-10-CM Range Z66-Z66
Do not resuscitate status
ICD-10-CM Range Z67-Z67
Blood type
ICD-10-CM Range Z68-Z68
Body mass index (BMI)- Z68 Body mass index [BMI]
ICD-10-CM Range Z69-Z76
Persons encountering health services in other circumstances- Z69 Encounter for mental health services for...
- Z70 Counseling related to sexual attitude, b...
- Z71 Persons encountering health services for...
- Z72 Problems related to lifestyle
- Z73 Problems related to life management diff...
- Z74 Problems related to care provider depend...
- Z75 Problems related to medical facilities a...
- Z76 Persons encountering health services in ...
ICD-10-CM Range Z77-Z99
Persons with potential health hazards related to family and personal history and certain conditions influencing health status
Code Also
- any follow-up examination (Z08-Z09)
- Z77 Other contact with and (suspected) expos...
- Z78 Other specified health status
- Z79 Long term (current) drug therapy
- Z80 Family history of primary malignant neop...
- Z81 Family history of mental and behavioral ...
- Z82 Family history of certain disabilities a...
- Z83 Family history of other specific disorde...
- Z84 Family history of other conditions
- Z85 Personal history of malignant neoplasm
- Z86 Personal history of certain other diseas...
- Z87 Personal history of other diseases and c...
- Z88 Allergy status to drugs, medicaments and...
- Z89 Acquired absence of limb
- Z90 Acquired absence of organs, not elsewher...
- Z91 Personal risk factors, not elsewhere cla...
- Z92 Personal history of medical treatment
- Z93 Artificial opening status
- Z94 Transplanted organ and tissue status
- Z95 Presence of cardiac and vascular implant...
- Z96 Presence of other functional implants
- Z97 Presence of other devices
- Z98 Other postprocedural states
- Z99 Dependence on enabling machines and devi...