Reporting Procedures Not Carried Out

ICD-10-CM “Z” codes are reported for factors influencing health status and contact with health care services. These codes may be reported in any healthcare setting and in general, may be reported as either a primary or secondary diagnosis depending upon circumstances.  

Z codes are not procedure codes. They provide a reason for the encounter. To describe any procedure performed during the encounter, a procedure code must be reported in addition to a Z code.

Z codes can provide additional information about encounters. As an example, codes from the Z28 and Z53 code series can be reported when immunizations or procedures are not carried out for various reasons. These codes should be added to the record to identify circumstances when scheduled services are not performed due to the patient’s decision or other reasons.

Z28

Z28 Immunization not carried out and underimmunization status

 Z28.0 Immunization not carried out because of contraindication

Z28.01 Immunization not carried out because of acute illness of patient

Z28.02 Immunization not carried out because of chronic illness or condition of patient

Z28.03 Immunization not carried out because of immune compromised state of patient

Z28.04 Immunization not carried out because of patient allergy to vaccine or component

Z28.09 Immunization not carried out because of other contraindication

Z28.1 Immunization not carried out because of patient decision for reasons of belief or group pressure

Z28.2 Immunization not carried out because of patient decision for other and unspecified reason

Z28.20 Immunization not carried out because of patient decision for unspecified reason

Z28.21 Immunization not carried out because of patient refusal

Z28.29 Immunization not carried out because of patient decision for other reason

  Z28.8 Immunization not carried out for other reason

Z28.81 Immunization not carried out due to patient having had the disease

Z28.82 Immunization not carried out because of caregiver refusal

Z28.83 Immunization not carried out due to unavailability of vaccine

Z28.89 Immunization not carried out for other reason

Z28.9 Immunization not carried out for unspecified reason

Z53

Z53 Persons encountering health services for specific procedures and treatment, not carried out

Z53.0 Procedure and treatment not carried out because of contraindication

Z53.01 Procedure and treatment not carried out due to patient smoking

Z53.09 Procedure and treatment not carried out because of other contraindication

Z53.1 Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure

Z53.2 Procedure and treatment not carried out because of patient's decision for other and unspecified reasons

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

Z53.8 Procedure and treatment not carried out for other reasons

Z53.9 Procedure and treatment not carried out, unspecified reason

A person’s refusal of medical care or immunizations may endanger the person or the public health and welfare and may also impact allocation of health care resources. Providers should report procedures not carried out codes for data collection as well as to provide the rationale in the patient record for scheduled procedures that are not performed. Collection of this data is crucial in developing and tracking quality measures associated with social determinants of health (SDOH).

For more information on SDOH, visit the following websites: https://www.cdc.gov/socialdeterminants/; https://ncbi.nlm.nih.gov/pmc/articles/PMC2099283/

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