Contraceptive Visits - Reproductive Health National ...
ICD-10 Codes for Family Planning ServicesThe purpose of this job aid is to provide a comprehensive list of ICD-10 codes for family planning services, including contraceptive visits, sexually transmitted infection services, female and male genital tract conditions, achieving pregnancy and basic infertility services, and other selected counseling services. Family planning agencies can customize this list based on the services they provide.Contraceptive VisitsTable 1. METHOD INITIATION VISITSCodeDefinitionCommentZ30.011Initial prescription (Rx) of oral contraceptive (OC)Includes combined and progestin-only pillsZ30.012Rx of emergency contraception (EC)All emergency contraception pills (ECPs). Optional for copper intrauterine device (IUD) used as EC Z30.013Initial Rx of injectable contraceptiveIncludes DMPA-IM and DMPA-SQ (Depo-Provera)Z30.014Initial Rx of IUDUse on Z30.430 on the day of insertion Z30.015Initial Rx of vaginal ring contraceptiveAll contraceptive vaginal ring productsZ30.016Initial Rx of transdermal patch contraceptiveAll contraceptive transdermal productsZ30.017Initial Rx of implantable subdermal contraceptiveInsertion of etonogestrel implant (Nexplanon)Z30.018Initial Rx of other contraceptivesBarrier methods (diaphragm, condom)Z30.019Initial Rx of contraceptives, unspecifiedUse more specific codes when availableTable 2. METHOD FOLLOW-UP VISITSCodeDefinitionCommentZ30.40Surveillance of contraceptives, unspecifiedUse more specific codes when availableZ30.41Surveillance of OC userInclude combined and progestin-only pillsZ30.42Surveillance of injectable contraceptiveRoutine DMPA-IM and DMPA-SQ injection visits Z30.430Insertion of IUDUse on the day of IUD insertionZ30.431Routine checking of IUDIUD follow-up visitsZ30.432Removal of IUDIUD removal Z30.433Removal + reinsertion of IUDIUD exchangeZ30.44Surveillance of vaginal ringAll contraceptive vaginal ring productsZ30.45Surveillance of transdermal patchAll contraceptive transdermal productsZ30.46Surveillance of implantable subdermal contraceptiveIncludes checking, removal, exchange of implantZ30.49Surveillance of other contraceptivesBarrier methods (diaphragm, condom) Table 3. OTHER CONTRACEPTIVE CODESCodeDefinitionCommentZ30.02Counseling in natural family planning (NFP) to avoid pregnancyFertility awareness-based method (FABM) counseling Z30.09Other general counseling on contraceptionCounseling occurred, but no method started. Use for method counseling on same day of long-acting reversible contraception (LARC) procedureZ30.2Sterilization procedureDay of vasectomy or tubal occlusion procedureZ30.8Other contraceptive managementRoutine exam for contraceptive maintenance.Encounter for post-vasectomy sperm countZ30.9Contraceptive management, unspecifiedUse more specific codes when availableZ97.5Presence of IUDUse for evaluation of missing IUD string Z98.51Tubal ligation statusHistory of tubal occlusion, or use to evaluate possible tubal occlusion failureZ98.52Vasectomy statusHistory of vasectomy, or use to evaluate fertility of sterility after vasectomyTable 4. CONTRACEPTIVE COMPLICATIONSCodeDefinitionCommentR55Syncope (vasovagal)Syncope during office procedureT81.4xx-Infection following a procedure, unspecifiedPost-IUD pelvic inflammatory disease (PID) or post-implant site infectionsT83.31x-Mechanical breakdown of IUDExpired; broken or bent armT83.32x-Displacement of IUDMalposition, missing string, partial expulsionT83.39x-Other mechanical complication of IUDPerforation, embedment, translocationT85.618-Mechanical breakdown of implant Expired, fractured implantT85.628-Displacement of implantMalposition, missing, partial expulsionT85.698-Other mechanical complication of implantNerve or vascular injury from implantT85.79x-Infection and inflammatory reaction due to implantInfection over implant site 7th digit on complication codes: A: initial encounter D: subsequent encounter S: sequelaeTable 5. PREGNANCY EVALUATIONCodeDefinitionCommentZ32.00Pregnancy test/exam, not confirmedPregnancy test inconclusiveZ32.01Pregnancy test/exam, positivePositive pregnancy testZ32.02Pregnancy test/exam, negativeNegative pregnancy testTable 6. PREVENTIVE MEDICINE VISITSCodeDefinitionCommentZ00.00General adult medical exam without abnormal findingsComprehensive health screening, no new abnormal findingsZ00.01General adult medical exam with abnormal findings*Comprehensive health screening, with new abnormal findingsZ01.41Encounter for routine gynecological examinationNon-billable code; use one of the 2 codes belowZ01.411Gyn. exam with abnormal findings*Well woman visit, with new abnormal findingsZ01.419Gyn. exam without abnormal findingsWell woman visit, without new abnormal findingsZ12.39Screening breast examUse when the encounter is not a well woman visit or periodic health screening Z23Encounter for immunizationVisit for HPV-9 vaccine or others*Include code for the abnormal finding as a secondary diagnosis.Sexually Transmitted Infection Services (Female and Male)Table 7. SEXUALLY TRANSMITTED INFECTION SCREENING AND COUNSELINGCodeDefinitionCommentZ11.3Encounter for screening for infections with a predominantly sexual mode of transmissionScreening for sexually transmitted infection (STI)Z11.4Screening for human immunodeficiency virus (HIV)HIV screening test(s) performed or orderedZ11.51Screening for human papillomavirus (HPV)Use for follow-up of certain abnormal cytology and HPV test results and post-treatment surveillance Z11.59Screening for other viral diseasesGenital herpes screeningZ11.6Screening for other protozoal diseases Vaginal trichomoniasis screeningZ11.8Screening for other infectious and parasitic diseases Gonorrhea, chlamydia, and syphilis screeningZ20.2Contact with or exposure to STIRecent contact (exposure) to a STI, specifically CT, GC, non-gonococcal urethritis, epididymitis, trichomoniasis, or syphilisZ22.4Carrier/suspected carrier of STIDiagnosed with trichomoniasis (women), syphilis, or HIV, either confirmed or presumptively treated, who may be co-infected with CT or GCZ20.5Contact with and (suspected) exposure to viral hepatitisExposure to hepatitis A, B, or CZ20.6Contact with and (suspected) exposure to HIVExposure to HIVZ71.7HIV counselingCounseling re: HIV prevention, diagnosis, treatmentZ71.89Other specified counselingCounseling on a specific topic, not elsewhere classifiedZ71.9Counseling, unspecifiedGeneral counseling on a variety of topicsZ72.51High-risk heterosexual behaviorTargeted STI screeningZ72.52High-risk homosexual behaviorTargeted STI screeningZ72.53High-risk bisexual behaviorTargeted STI screeningZ86.19Personal history of certain other infectious and parasitic diseasesIncludes personal history of STI. Retesting after treatment of CT or GCTable 8. CHLAMYDIA CodeDefinitionCommentA56.00Chlamydial infection lower genitourinary (GU) tract, unspecifiedUse more specific codes when availableA56.01Chlamydial cystitis and urethritisChlamydial urethritisA56.09Other chlamydial infection of lower GU tractChlamydial cervicitisA56.19Other chlamydial GU infectionChlamydia epididymitis or orchitisA56.3Chlamydial proctitis (anus/rectum)Chlamydial proctitisA56.4Chlamydial infection of pharynxChlamydial pharyngitisA56.8Sexually transmitted chlamydia other sitesSexually transmitted chlamydia, other sitesN34.1Non-specific urethritisAlso called non-gonococcal urethritisN72CervicitisUse for mucopurulent discharge, cause unknownTable 9. ECTOPARASITESCodeDefinitionCommentB85.3PhthiriasisPubic crab liceB86Scabies Infestation with scabiesTable 10. GENITAL HERPESCodeDefinitionCommentA60.00Herpes of urogenital system, unspecifiedHerpes vesicle, pustule, ulcer, or crust multiple sitesA60.01Herpetic ulceration of penisHerpes lesion on penisA60.02Herpes of other male genital organsHerpes lesion on scrotumA60.03Herpes cervicitisHerpes lesion on cervixA60.04Herpetic vulvovaginitisHerpes lesion on vulvaA60.09Anogenital herpes infection, specified siteHerpes lesion other than specified aboveA60.1Herpes of perianal skin and rectumHerpes lesion on around anusA60.9Anogenital herpes infection, unspecifiedRecurrent anogenital herpesK62.6Ulcer of anus, rectumUse if cause of anal ulcer is unknownTable 11. GENITAL WARTSCodeDefinitionCommentA63.0Anogenital (venereal) wartsCondyloma acuminatumB07.9Viral warts, unspecifiedUse when type of wart is unknownB08.1Molluscum contagiosumMolluscum contagiosumTable 12. GONORRHEA CodeDefinitionCommentA54.00Gonococcal infection of lower genitourinary tract, unspecifiedAcute gonorrhea, lower genitourinary tractA54.01Cystitis and urethritis, unspecifiedGonococcal urethritis (female, male)A54.03Gonococcal cervicitis, unspecifiedAcute gonococcal cervicitis (female)A54.09Other gonococcal infection of lower genitourinary tractGC at sites other than those listedA54.1Gonococcal periurethral and accessory gland abscessGonococcal Bartholin duct abscessA54.22Gonococcal prostatitisGonococcal prostatitis (male)A54.23Gonococcal infection of other male genital organsGonococcal epididymitis or orchitis (male)A54.24Gonococcal PIDGonococcal PID (female)A54.29Other gonococcal genitourinary infectionAcute gonorrhea, upper genitourinary tractA54.5Gonococcal pharyngitisGonococcal pharyngitis (female, male)A54.6Proctitis (anus/rectum)Gonococcal proctitis (female, male)Table 13. PELVIC INFLAMMATORY DISEASE (PID)CodeDefinitionCommentA56.11Chlamydial PIDChlamydial PIDA56.24Gonococcal PIDGonococcal PIDN70.11Chronic salpingitisHydrosalpinxN70.13Chronic salpingitis and oophoritisChronic PIDN70.93Salpingitis and oophoritis, unspecifiedTubo-ovarian abscess N71.0Acute inflammatory disease of uterusEndometritis/myometritisN73.9PID, unspecifiedAcute PID (not known to be chlamydial or gonococcal)Table 14. SYPHILISCodeDefinitionCommentA51.0Primary genital syphilisPrimary syphilis, genital chancre A51.1Primary anal syphilisPrimary syphilis, anal chancreA51.31Condyloma latumWarts as a manifestation of secondary syphilisA51.39Other secondary syphilis of skinSyphilitic mucous patch, syphilitic leukodermaA51.5Early syphilis, latentAsymptomatic syphilis, < 2 years after infectionA52.8Late syphilis, latentAsymptomatic syphilis, > 2 years after infection or unknown durationA52.9Late syphilis, unspecifiedSyphilis of unknown durationA53.9Syphilis, unspecifiedUse more specific codes when availableGenital Tract Conditions (Female and Male)Table 15. VULVAR INFECTION & INFLAMMATIONCodeDefinitionCommentB35.6Tinea crurisJock itch, “ring worm” of vulvaN75.0Cyst of Bartholin's glandBartholin duct cyst (non-infected)N75.1Abscess of Bartholin's glandBartholin duct abscessN76.2Acute vulvitisAcute vulvar rash, unknown causeN76.3Subacute and chronic vulvitisChronic vulvar rash, unknown causeN76.4Abscess of vulvaAcute abscess of labia majora or minoraN76.6Ulceration of vulvaVulvar ulcer, unknown causeTable 16. NON-INFECTIOUS VULVAR CONDITIONSCodeDefinitionCommentD07.1Carcinoma in situ of vulvaHigh-grade squamous intraepithelial lesion (HSIL) of vulva. Vulvar intraepithelial neoplasia (VIN) 3 (older term)D28.0Vulvar neoplasm, benignSkin tagsL28.0Lichen simplex chronicusSquamous cell hyperplasia, neurodermatitisL90.0Lichen sclerosus et atrophicusVulvar lichen sclerosusN84.3Polyp of vulvaLabial and vulvar polypsN90.0Mild vulvar dysplasiaLow-grade squamous intraepithelial lesion (LSIL) of vulva (new term); VIN 1 (older term)N90.3Dysplasia of vulva, unspecifiedVIN, unspecifiedN90.4Leukoplakia of vulvaWhite lesion of vulva, not yet diagnosed N90.5Atrophy of vulvaStenosis of vulvaN90.810Female genital mutilation status, unspecifiedFemale genital cuttingN90.89Other specified non-inflammatory disorders of vulva and perineumAdhesions of vulvaTable 17. VAGINAL INFECTIONSCodeDefinitionCommentA59.01Trichomonas vulvovaginitisVaginal trichomoniasisB37.3Candidiasis of vulva and vaginaVaginal candidiasisN76.0Acute vaginitisAcute bacterial vaginosis (BV) or undiagnosed acute vaginitisN76.1Subacute and chronic vaginitisRecurrent BV or undiagnosed recurrent vaginitisTable 18. CERVICAL CONDITIONSCodeDefinitionCommentD06.0Cervical intraepithelial neoplasia (CIN) 3 endocervixPositive endocervical curettage (ECC)D06.1CIN 3 exocervixHSIL/CIN 3 (biopsy diagnosis)D06.9Carcinoma in situ of cervix, unspecifiedAdenocarcinoma in situ (AIS) of cervixN86Erosion/ectropion cervixRing of columnar epithelium surrounding cervical os N87.0CIN 1 LSIL/CIN 1 (biopsy diagnosis)N87.1CIN 2 HSIL/CIN 2 (biopsy diagnosis)N88.1LeukoplakiaWhite lesion of cervix without vinegar, undiagnosedN88.2Stricture/stenosis of cervixCervical stenosisN84.1Cervical polypEndocervical polypTable 19. CERVICAL AND VAGINAL CANCER SCREENING CodeDefinitionCommentR87.619AGC cytologyAtypical glandular cells of cervix not otherwise specifiedR87.610ASC-US cytologyAtypical squamous cells of undetermined significance R87.611ASC-H cytologyAtypical squamous cells cannot exclude HSIL R87.612LSIL cytologyLow-grade SIL R87.613HSIL cytologyHigh-grade SIL R87.614Cytologic evidence of malignancyEvidence of malignancy on cervical cytologyR87.615Unsatisfactory cytologic smear of cervixInadequate specimenR87.616Satisfactory smear but lacking transformation zoneFew or no endocervical cells on cervical cytologyR87.810Cervical high-risk HPV DNA test positiveHigh-risk HPV test positive Z01.42Cervical smear to confirm findings of recent normal smear following initial abnormal smearRepeat cytology to confirm findings of recent normal cytology following initial abnormal Z12.4Screening for malignant neoplasm of cervixScreening for cervical cancer and precursorsZ12.72Screening for malignant neoplasm of vaginaScreening for vaginal cancer and precursorsZ85.41Personal history of malignant neoplasm of cervix uteriHistory of cervical cancerZ87.42Personal history of other diseases of the female genital tractHistory of abnormal cytology or histologyTable 20. BREAST CONDITIONSCodeDefinitionCommentN60.(11/12)Diffuse cystic mastopathy (right, left)Fibrocystic changeN63.0Unspecified lump in unspecified breastMass or lump not yet diagnosedN63.1Unspecified lump in the right breastMass or lump not yet diagnosed, rightN63.2Unspecified lump in the left breastMass or lump not yet diagnosed, leftN64.3Galactorrhea not associated with childbirthMilky nipple dischargeN64.4MastodyniaBreast painN64.52Nipple dischargeSerous, green, or bloody nipple dischargeN64.53Retraction of nippleCongenital or acquitted retraction, benignN64.59Other signs/symptoms in breastChanges in nipples, including new onset inversionO91.12Abscess of breast associated with the puerperiumBreast abscess during lactationO91.13Abscess of breast associated with lactationPurulent mastitis associated with lactationO91.23Non-purulent mastitis associated with lactationMastitis (breast inflammation) during lactationR92.8Abnormal mammogramAbnormal findings on diagnostic imaging of breastTable 21. URINARY TRACT CONDITIONSCodeDefinitionCommentN10Acute pyelonephritisAcute kidney infectionN30.00Acute cystitis without hematuriaBladder infection without blood in urineN30.01Acute cystitis with hematuriaAka: hemorrhagic cystitisN34.3Urethral syndrome, unspecifiedUrethritis without bacteriaN39.3Stress incontinenceUrinary stress incontinence (female, male)N39.41Urge incontinenceUrinary urge incontinence (female, male)N39.46Mixed incontinenceUrge and stress incontinence (female, male)R30.0DysuriaPainful urinationR31.9Hematuria, unspecifiedBlood in urine, not yet diagnosedR35.0Frequency of micturitionUrinary frequency (small volume of urine)R35.8Other polyuriaExcessive urination (large volume of urine)R39.15Urgency of urinationUrinary urgencyTable 22. GYNECOLOGICAL PROBLEMSCodeDefinitionCommentD25.9Leiomyoma of uterus, unspecifiedUterine “fibroid” or myomaL68.0HirsutismAndrogen-dependent hirsutismE28.2Polycystic ovarian syndrome (PCOS)Referred to as PCOSF52.0Hypoactive sexual desire disorderNo or low motivation for sexual activity, problematicF52.22Female sexual arousal disorderUnsatisfied with ability to become sexually arousedF52.31Female orgasmic disorderUnsatisfied with ability to orgasmN80.3Endometriosis of pelvic peritoneumEndometriosis of pelvisN84.0Polyp of corpus uteriEndometrial polypN85.7HematometraCollection of blood or clot in the uterusN83.01/.02Follicular cyst of ovary (right, left)Benign ovarian cyst, before ovulationN83.11/.12Corpus luteum cyst of ovary (right, left)Benign ovarian cyst, after ovulationN83.201/.202Unspecified ovarian cysts (right, left)Other and unspecified ovarian cystsN91.0Primary amenorrheaAbsent or delayed menarche (first menstrual period)N91.1Secondary amenorrheaMissed menses (> 3 menses or 6 months without menses)N91.2Amenorrhea, unspecifiedUse more specific codes aboveN91.3Primary oligomenorrheaCycle interval >35 days, present since menarcheN91.4Secondary oligomenorrheaCycle interval >35 days, developed after menarcheN92.0Excessive menstruation with regular cycleHeavy menstrual bleeding; menorrhagiaN92.1Excessive and frequent menstruation with irregular cycleMenometrorrhagia, metrorrhagiaN92.2Excessive menstruation at pubertyExcessive bleeding with onset of menstrual periodsN92.3Ovulation bleedingMid-cycle vaginal bleedingN92.4Excessive bleeding in the premenopausal periodPerimenopausal menorrhagia or metrorrhagiaN92.6Irregular menstruation, unspecifiedIrregular menstrual cycles, not otherwise specifiedN93.9Abnormal uterine and vaginal bleeding Abnormal vaginal bleeding not yet diagnosedN95.0Postmenopausal bleedingVaginal bleeding > 1 year after final menstrual periodN95.1Menopausal and female climacteric statesMenopausal symptoms (hot flashes/flushes)N95.2Atrophic vaginitisGenitourinary syndrome of menopause (GSM); new nameR68.82Decreased libidoDecreased sexual desire (symptom, not disorder)Table 23. PAIN SYNDROMESCodeDefinitionCommentF32.81Premenstrual dysphoric disorder Severe form of premenstrual syndrome (PMS)F52.5Vaginismus not due to a substance or known physiological conditionVaginismus, unknown causeF52.6Dyspareunia not due to a substance or known physiological conditionPainful intercourse, unknown causeG43.001Migraine, without auraSimple migraineG43.101Migraine, with auraClassical migraineG43.829Migraine menstrual intractableMenstrual (catamenial) migraineG43.909Migraine, unspecifiedMigraine, unknown typeG44.209Headache, tensionTension headachesR51.9Headache, unspecifiedHeadache type unknown or not yet diagnosedM60.8-851Myofascial painChronic pelvic pain syndromeN94.0MittelschmerzMid-cycle pain associated with ovulationN94.10Unspecified dyspareuniaPainful intercourse, during or afterwardN94.11Superficial (introital) dyspareuniaSexual pain at introitusN94.12Deep dyspareuniaSexual pain in abdomenN94.19Other specified dyspareuniaSexual pain in vaginaN94.2Vaginismus secondary to physiologic conditionPainful tightening or spasm of vaginal musclesN94.3Premenstrual tension syndromePMSN94.4Primary dysmenorrhea Painful menstrual cramps since menarcheN94.5Secondary dysmenorrhea Painful menstrual cramps, starting after menarcheN94.6Dysmenorrhea, unspecifiedPainful menstrual crampsN94.810Vulvar vestibulitisAlso called localized provoked vulvodyniaN94.819Vulvodynia, unspecifiedVulvodynia, not yet diagnosedR10.10Upper abdominal pain, unspecifiedEpigastric painR10.2Pelvic and perineal painAcute pelvic pain undiagnosedR10.30Lower abdominal pain, unspecifiedLower abdominal pain, not yet diagnosedR10.31Right lower quadrant painAbdominal pain, right lower quadrant (RLQ)R10.32Left lower quadrant painAbdominal pain, left lower quadrant (LLQ)R10.33Periumbilical painMid-abdominal pain at level of umbilicusTable 24. MALE GENITAL TRACT CONDITIONSCodeDefinitionCommentF52.21Male erectile disorderDifficulty obtaining or maintaining erectionF52.4Premature ejaculationPremature ejaculation causes distressN34.1Nonspecific urethritis Non-gonococcal urethritis (NGU) N34.2Other urethritisBacterial urethritis; urethral meatitisN41.0Prostatitis, acuteAcute prostate gland infectionN41.1Prostatitis, chronicChronic prostate gland infectionN43.3Hydrocele, unspecifiedFluid fill sac around testicleN44.00Torsion of testis, unspecifiedTesticular torsionN45.1EpididymitisInflammation of the epididymis, the cordlike structure attached to the posterior of the testis N45.3Epididymo-orchitisInflammation of the testicle and epididymisN48.1Balanitisinflammation of tip of penisR10.2Pelvic and perineal painPain in the perineum, pubic region, or scrotum R21Rash or non-specific skin eruptionGenital rash, not yet diagnosed R36.0Urethral discharge w/o bloodUrethral discharge, not bloody or painfulR36.1HematospermiaBlood in semenR36.9Urethral discharge unspecifiedPenile discharge, not yet diagnosed Table 25. OTHER SIGNS AND SYMPTOMSCodeDefinitionCommentR11.0Nausea, aloneNausea without vomitingR11.11Vomiting, aloneVomiting without nausea R11.2Nausea with vomitingBoth nausea with vomitingR50.9Fever, unspecifiedPersistent fever; fever with chillsR53.1WeaknessSameR53.81Other malaiseMalaise, not specifiedAchieving Pregnancy and Basic InfertilityTable 26. INFERTILITYCodeDefinitionCommentN46.9Male infertility, unspecifiedMale factor infertilityN97.0Female infertility associated with anovulationOligo-anovulation, poor ovulatory qualityN97.1Female infertility of tubal originPartial or complete occlusion of fallopian tubesN97.2Female infertility of uterine originSub-mucus fibroid, congenital anomaly of endometrium or corpusN97.8Female infertility of other originCervical factor infertilityN97.9Female infertility, unspecifiedFemale infertility, primary or secondaryZ31.41Fertility testing Encounter for sperm count for fertility testingZ31.81Encounter for male factor infertility in female patientEvaluation of male partner during infertility; evaluation of female Table 27. PROCREATIVE MANAGEMENTCodeDefinitionCommentZ31.41Encounter for fertility testingInfertility study(ies) doneZ31.5Encounter for procreative genetic counselingOrdering or explaining of genetic test resultsZ31.61Procreative counseling/advice using NFPAchieving pregnancy counselingZ31.69Other procreative managementPrepregnancy care; preconception care (older term)Z31. 9Encounter for procreative management, unspecifiedUse more specific codes when availableOther Counseling ServicesTable 28. BEHAVIORAL HEALTH CodeDefinitionCommentF10.10Alcohol abuse, uncomplicatedSameF10.20Alcohol dependence, uncomplicatedSameF10.21Alcohol dependence, in remissionSameF11.10Opioid abuse, uncomplicatedSameF11.20Opioid dependence, uncomplicatedSameF11.21Opioid dependence, in remissionSameF11.90Opioid use, unspecified, uncomplicatedUse more specific codes when availableF17.200Nicotine dependence, unspecified, uncomplicatedTobacco use disorder, mild-moderate-severeZ71.41Alcohol abuse counseling and surveillance of alcoholicSameZ71.51Drug abuse counseling and surveillance of drug abuserSameZ71.6Tobacco abuse counselingSmoking cessation counselingF32.9Depressive disorder, single episodeSameF33.9Depressive disorder, recurrentSameF41.1Generalized anxiety disorderSameZ60.(0-9)Problems of adjustment to life-cycle transitionsProblems related to social environmentZ71.89Other specified counselingCounseling on other specific topicsZ71.9Counseling not otherwise specified?General counseling Table 29. WEIGHT AND EATING DISORDERSCodeDefinitionCommentE66.01Obesity, morbidBody mass index (BMI) >40 kg/m2E66.09Other obesityBMI 30–39 kg/m2E66.3OverweightBMI 26–29 kg/m2F50.0Anorexia nervosa, unspecifiedSameF50.9Eating disorder, unspecifiedAtypical anorexia nervosa or bulimia nervosaZ71.3Dietary counseling and surveillanceWeight management counselingTable 30. PrEP (PRE-EXPOSURE PROPHYLAXIS)CodeDefinitionCommentZ01.812Encounter for preprocedural lab examUse for blood or urine tests prior to treatmentZ11.3Encounter for screening for infections with a predominantly sexual mode of transmissionScreening for STIZ11.4Encounter for screening for HIV HIV screening test(s) performed or ordered Z11.59Encounter for screening for other viral diseasesGenital herpes screeningZ20.2Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmissionRecent exposure to a STI, including CT, GC, non-gonococcal urethritis, epididymitis, trichomoniasis, or syphilisZ20.6Contact with and (suspected) exposure to HIVExposure to HIVZ51.81Encounter for therapeutic drug level monitoringPrEP monitoringZ71.7Encounter for HIV counselingCounseling re: HIV prevention, diagnosis, treatmentZ72,89Other problems related to lifestyleUse for drug-seeking behavior or unhealthy drinking behaviorZ79.899Other long-term (current) drug therapyPrEP monitoringTable 31. PEP (POST-EXPOSURE PROPHYLAXIS)CodeDefinitionCommentZ20.2Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmissionScreening for STI Z20.5Contact with and (suspected) exposure to viral hepatitisExposure to hepatitis A, B, or CZ20.6Contact with and (suspected) exposure to HIVExposure to HIVZ77.21Contact with and (suspected) exposure to potentially hazardous body fluidsSameW46.0XXAContact with hypodermic needle (initial encounter (enc.))Hypodermic needle stick, initial encounterW46.0XXDContact with hypodermic needle (subsequent enc.)Hypodermic needle stick, subsequent encounterW46.1XXAContact with contaminated hypodermic needle (initial enc.)Contaminated hypodermic needle stick, initial encounterW46.1XXDContact with contaminated hypodermic needle (subsequent enc.)Contaminated hypodermic needle stick, subsequent encounterTRANSGENDER SERVICESCodeDefinitionCommentF64.0TranssexualismA transgender person, especially one whose body has been altered through surgery or hormone therapy to bring into alignment with gender identityF64.1Dual role transvestismPerson who wears clothes of the opposite sex temporarily, but does not want gender reassignmentF64.2Gender identity disorder of childhoodApplicable to patients aged 0–17 years inclusive. Separate criteria for girls and boysF64.8Other gender identity disordersSpecified, but not elsewhere classifiedF64.9Gender identity disorder, unspecifiedUse more specific codes when availableZ87.890Personal history of sex reassignmentHistory of sexual reassignment surgeryReference:American Medical Association (AMA). (September 20, 2020). ICD-10-CM 2021: The Complete Official Codebook with Guidelines. (2019). This publication was supported by the Office of Population Affairs (Grant FPTPA006030). The views expressed do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. ................
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