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2025 ICD-10-CM code Z02.83

Encounter for blood alcohol and blood drug test.Use additional code for findings of alcohol or drugs in blood.

Always code the specific reason for the encounter, and use additional codes to specify any findings. Ensure that proper documentation supports the medical necessity of the tests and the interpretation of the results.

No modifiers are typically used with Z02.83 since it is a diagnosis code.

Medical necessity for blood alcohol and drug testing varies depending on context. It might be mandated by law (e.g., following a motor vehicle accident), required by employers (pre-employment screening), or clinically indicated due to suspicion of substance abuse. The physician's documentation must clearly justify the need for the test based on the patient's clinical presentation and the rationale for ordering the test.

The clinical responsibility for this code involves ordering and interpreting the blood alcohol and drug tests, explaining the results to the patient, and providing appropriate follow-up care or referral as needed.This may involve physicians, nurses, physician assistants, or other qualified healthcare professionals, depending on the setting and patient needs.

IMPORTANT:If positive results for alcohol or drugs are found, additional codes from category R78 (Abnormal findings of blood and blood-forming organs) should be used to classify the specific substance(s) detected.Consider additional codes to reflect the reason for ordering the blood alcohol and blood drug test (e.g., suspected substance abuse, pre-employment screening, legal requirement).

In simple words: This code is used when someone goes to the doctor or clinic specifically to have their blood tested for alcohol and drugs. If the test shows alcohol or drugs are present, the doctor will use a different code to describe that finding.

This ICD-10-CM code signifies an encounter with healthcare services specifically for the purpose of conducting blood alcohol and blood drug testing.The code is applied when the primary reason for the visit is to perform these tests, regardless of the patient's overall health status.It is crucial to note that if a positive result for alcohol or drugs in the blood is detected, an additional code should be used to classify the specific finding(s).

Example 1: A patient is brought to the emergency department (ED) after a motor vehicle accident. Blood alcohol and drug testing are ordered to assess the patient's impairment level.Code Z02.83 is used to indicate the encounter for testing, and additional codes will reflect any positive findings., A patient presents for a pre-employment physical examination, which includes blood alcohol and drug screening.Z02.83 is used to code the encounter for this screening purpose. No additional code would be necessary unless substance use is detected. , A probation officer mandates blood alcohol and drug testing for a patient as a condition of their probation.The healthcare provider uses Z02.83 to document this encounter.

Medical record documentation must clearly support the reason for the blood alcohol and blood drug testing. This includes the order for the tests, the results of the tests (both positive and negative), and any clinical actions or recommendations based on the results.The documentation should also justify the medical necessity of the testing (e.g., pre-employment screening, legal mandate, clinical suspicion of substance abuse).

** Z codes, including Z02.83, represent reasons for encounters and should always be accompanied by a procedure code if a procedure is performed.The code should only be used when the primary reason for the encounter is blood alcohol and drug testing.If the blood test is part of a broader examination, Z02.83 may not be the most appropriate code.

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