Just because they were uncooperative during the visit, doesn't mean that should be coded as the diagnosis. You should code based on the nature of the presenting problem. Further, I would not recommend you append any mental health codes in this instance.
Patient's noncompliance with other medical treatment and regimen. The 2020 edition of ICD-10-CM Z91.19 became effective on October 1, 2019. This is the American ICD-10-CM version of Z91.19 - other international versions of ICD-10 Z91.19 may differ.
Procedure and treatment not carried out, unspecified reason. Z53.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2018/2019 edition of ICD-10-CM Z53.9 became effective on October 1, 2018.
Z91.19 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 Z91.19 became effective on October 1, 2020. This is the American ICD-10-CM version of Z91.19 - other international versions of ICD-10 Z91.19 may differ. Z codes represent reasons for encounters.
1 for Patient's noncompliance with medical treatment and regimen is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
R45. 6 - Violent behavior | ICD-10-CM.
ICD-10 Code for Procedure and treatment not carried out because of other contraindication- Z53. 09- Codify by AAPC.
In general, non-compliance in healthcare is when individuals do not follow the rules, regulations, and laws that relate to healthcare practices. While this could include patients not complying with medical orders, the focus here will be on regulatory non-compliance.
Using swear words and constantly contradicting people could be considered combative behavior. People who are combative are also often described as hostile, angry, or pugnacious.
Violent behavior is any behavior by an individual that threatens or actually harms or injures the individual or others or destroys property. Violent behavior often begins with verbal threats but over time escalates to involve physical harm.
Modifier 53 applies if the provider quits a procedure because the patient is at risk. In other words, the provider does not so much choose to discontinue the procedure, as sound medical practice compels him or her to do so.
Z53. 20 - Procedure and treatment not carried out because of patient's decision for unspecified reasons | ICD-10-CM.
Procedure and treatment not carried out, unspecified reason Z53. 9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z53.
Noncompliance is a NANDA nursing diagnosis described as the behavior of a patient and caregiver that does not correspond with the therapeutic plan agreed upon by the individual, family or guardian, and healthcare practitioner. Medication, treatments, follow-up appointments, and lifestyle changes are examples of this.
Discuss and document the patient's understanding of the consequences of continued noncompliance. If you are not able to discuss the consequences with the patient in person, explain them in a letter. Describe the actions the patient needs to take, such as calling the office or obtaining a diagnostic study.
Non-adherence: is generally a term which includes unintentional refusalby the patient (i.e. patient is overwhelmed, does not understand, helpless, confused, and/or concerned with healthcare costs).
The 2022 edition of ICD-10-CM Z53.9 became effective on October 1, 2021.
Z53.20 Procedure and treatment not carried out because of patient's decision for unspecified reasons. Z53.21 Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider. Z53.29 Procedure and treatment not carried out because of patient's decision for other reasons.
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.
FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)
Z91.14 is a billable diagnosis code used to specify a medical diagnosis of patient's other noncompliance with medication regimen. The code Z91.14 is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.
Medication non-compliance due to visual impairment. Medication overuse. Medication taken at higher dose than recommended. Medication taken at lower dose than recommended. Misuse of medication. Mixes medication with alcohol. Non-compliance of drug therapy. Non-compliance of drug therapy. Noncompliance with antiretroviral medication regimen.
The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:
Diagnosis was not present at time of inpatient admission. Documentation insufficient to determine if the condition was present at the time of inpatient admission. Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.
Z91.14 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.