Cracking the Code

Screening Diagnosis Code

Chapter 21 of the ICD-10-CM coding guidelines houses the “Z” codes for medical coding. This chapter provides specific information and instructions about how to properly report factors that influence health status and contact with health services. In this chapter, there is direct guidance for how to accurately report screening diagnosis codes.

A screening involves testing for disease or disease precursors so that early detection and treatment can be provided for people who test positive for a disease. With screening exams, the patient is asymptomatic. Per guidelines, a screening code may be a first-listed code if the reason for the visit specifically pertains to the screening exam. When there are positive findings, this should be listed as secondary diagnoses. Please be sure to read a provider’s documentation in its entirety to determine the proper sequencing of the screening diagnosis code.

Q: A 52-year-old woman presents to the outpatient radiology department for a mammogram. The provider orders a breast cancer screening. The screening reveals a breast mass in the left breast.
A: Z12.31, encounter for screening mammogram for malignant neoplasm of breast
N63.20, unspecified lump in the left breast, unspecified quadrant
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.21.c.5. and AHA Coding Clinic Second Quarter 2003, page 4: Screening mammogram with positive findings
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