2025 ICD-10-CM code Z30.01
Encounter for initial prescription of contraceptives.
The medical necessity for contraception is based on the patient's desire to prevent pregnancy. The choice of contraceptive method is influenced by factors such as the patient's overall health, medical history, and personal preferences.
The provider is responsible for evaluating the patient's medical history, discussing various contraceptive options, prescribing the appropriate contraceptive method, and providing counseling on its use and potential side effects.
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- Persons encountering health services in circumstances related to reproduction (Z30-Z3A)
In simple words: This code is used when you see a doctor to get a prescription for birth control for the first time. It covers the visit for the prescription, counseling, and advice about birth control.
This code is used for encounters with health services for the initial prescription of contraceptives.It includes counseling and advice on contraception.
Example 1: A 25-year-old female visits her gynecologist for the first time to discuss birth control options. After a review of her medical history and discussion of the risks and benefits, the physician prescribes oral contraceptive pills. The encounter is coded as Z30.01., A 30-year-old female who recently gave birth visits her physician for a postpartum check-up and requests to start using contraception. The physician prescribes a contraceptive patch and provides instructions on its use. The encounter is coded as Z30.01., A 19-year-old female visits a family planning clinic to discuss her options for birth control. After counseling, she decides to use a vaginal ring and receives a prescription. The encounter is coded as Z30.01.
Documentation should include details of the patient's medical history, the contraceptive method prescribed, any counseling or education provided, and any relevant information discussed during the encounter, such as risks, benefits, and alternative methods.
** While Z30.01 covers the initial consultation and prescription for contraceptives, it does not include the actual insertion or application of certain contraceptive devices, such as IUDs or implants. These procedures would be coded separately.
- Specialties:Family Medicine, Obstetrics/Gynecology, Internal Medicine, Primary Care, Family Planning
- Place of Service:Office, Outpatient Hospital, Clinic, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home