Encounter for supervision of normal pregnancy, unspecified, first trimester. Z34.91 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2021 edition of ICD-10-CM Z34.91 became effective on October 1, 2020.
The CPT codes for reporting prenatal ultrasound fall under Diagnostic Ultrasound Procedures of the Pelvis Obstetrical and are as follows: 76801 – Standard first trimester ultrasound: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach
Encounter for antenatal screening of mother 1 Z36 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. 2 The 2021 edition of ICD-10-CM Z36 became effective on October 1, 2020. 3 This is the American ICD-10-CM version of Z36 - other international versions of ICD-10 Z36 may differ.
If a study is done to reassess fetal size, or to reevaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.
ICD-10 code Z36 for Encounter for antenatal screening of mother is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
The Current Procedural Terminology (CPT) code range for Diagnostic Ultrasound Procedures 76506-76999 is a medical code set maintained by the American Medical Association.
9.
9: Antenatal screening, unspecified.
76811– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation.
The most common or standard OB ultrasound study performed after the first trimester is described by CPT code 76805.
Z12. 11: Encounter for screening for malignant neoplasm of the colon.
Z12.11. Encounter for screening for malignant neoplasm of colon.
For example, Z12. 31 (Encounter for screening mammogram for malignant neoplasm of breast) is the correct code to use when you are ordering a routine mammogram for a patient. However, coders are coming across many routine mammogram orders that use Z12. 39 (Encounter for other screening for malignant neoplasm of breast).
ICD-10 code Z36, Encounter for antenatal screening of mother, is used when screening for the testing of disease or disease precursor is performed in patients who are seemingly well for the purpose of early detection and treatment.
Code Z33. 1 This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.
4 since you cannot code both the Z00. 00 and the Z01. 419 together on the same claim.
Encounter for supervision of normal pregnancy, unspecified, first trimester 1 Z34.91 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 Short description: Encntr for suprvsn of normal preg, unsp, first trimester 3 The 2021 edition of ICD-10-CM Z34.91 became effective on October 1, 2020. 4 This is the American ICD-10-CM version of Z34.91 - other international versions of ICD-10 Z34.91 may differ.
Z34.91 is applicable to maternity patients aged 12 - 55 years inclusive. Z34.91 is applicable to mothers in the first trimester of pregnancy, which is defined as less than 14 weeks since the first day of the last menstrual period. Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is ...
Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00 -Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
If you’re coding a report in which the provider does not document enough elements to reach the complete fetal and maternal evaluation codes, then you should resort to coding 76815. This exam is referred to as a “quick look” exam and includes one or more elements listed in the code description.
Most often, amniotic fluid will be evaluated and documented on the fetal anatomical structural evaluation at around 18 to 20 weeks.
The ACR explains that “among the required elements, ‘qualitative assessment of amniotic fluid volume’ refers to the radiologist’s statement, based on his or her experience and knowledge, that the volume is adequate or inadequate.”.
It is important to note that 76815 includes in its code description, “one or more fetuses,” and should not be coded more than once per study, or per fetus. If a study is done to reassess fetal size, or to reevaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.
Measurements appropriate for gestational age (older than or equal to 14 weeks, 0 days); Survey of intracranial/spinal/abdominal anatomy; Four-chambered heart; Umbilical cord assessment; Placenta location and amniotic fluid assessment; and. Examination of maternal adnexa, when visible.
After the first trimester, the amniotic fluid might be measured (quantitative), or the report may document this with a qualitative assessment — either is acceptable. If measured, this might also appear in the report simply as an abbreviation and a number.
Although amniotic fluid index (AFI) is not specifically documented as a key element, documentation should include amniotic fluid measurement with the second element for 76805: Measurements appropriate for gestational age (older than or equal to 14 weeks, 0 days). The ACR adds: