2025 ICD-10-CM code Z30.40
Encounter for surveillance of contraceptives, unspecified.
Medical necessity for this code is established by the patient's need for ongoing monitoring and management of their contraceptive method. This includes assessing efficacy, managing side effects, ensuring proper use, and providing patient education.
The healthcare provider is responsible for assessing the patient's continued need for contraception, evaluating the effectiveness of the current method, addressing any side effects or concerns, and providing ongoing counseling or education as needed.
- 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 visit a doctor or other healthcare provider to check how well your birth control is working, but the specific type of birth control is not recorded.
This code is used for encounters with healthcare providers for the purpose of monitoring or checking the effectiveness of a previously prescribed contraceptive method, where the specific type of contraceptive isn't specified.
Example 1: A patient has been using contraceptive pills for six months and visits their doctor for a routine check-up to discuss the effectiveness and any side effects., A patient with an IUD has an appointment to ensure the device is still in place and functioning correctly., A patient visits a family planning clinic for a follow-up appointment to discuss their current contraceptive method and explore other options.
Documentation should include the type of contraceptive being used, the reason for the surveillance visit (e.g., routine check-up, concerns about side effects), assessment of the patient's satisfaction with the method, and any changes or recommendations made.
** This code is distinct from codes for initial prescription or insertion of contraceptives (Z30.011-Z30.019 and Z30.430). It specifically addresses follow-up care and monitoring of existing contraceptive methods.The code was added to ICD-10-CM on October 1, 2015.
- Specialties:Family Medicine, Obstetrics and Gynecology, Women's Health, Primary Care
- Place of Service:Office, Outpatient Hospital, Clinic, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home