2025 ICD-10-CM code Z86.01
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99) 22. Factors influencing health status and contact with health services (Z00-Z99) Feed
Personal history of benign neoplasm.
This code is used to provide context to a patient's current health status or potential health risks.It does not typically drive medical necessity for procedures or further testing on its own, but it can inform clinical decision-making.
Clinicians use this code to document a patient's past medical history, which can be relevant to current or future care.It is not a primary diagnosis but rather provides context for the patient's overall health status.
- 22. Factors influencing health status and contact with health services (Z00-Z99)
- Z86. Personal history of certain other diseases
In simple words: The patient has a history of a non-cancerous tumor.
The patient has a documented history of a benign neoplasm, a growth of abnormal tissue that is not cancerous and does not spread to other parts of the body.
Example 1: A patient presents for an annual physical and reports a history of a benign skin mole removed several years ago. The code Z86.01 would be used to document this past history., A patient with a family history of breast cancer undergoes a mammogram. She also mentions a history of a fibroadenoma, a benign breast tumor.Z86.01 would be used to note this history., A patient is being evaluated for abdominal pain. During the history intake, they report a previous diagnosis of uterine fibroids, benign tumors of the uterus. Z86.01 can be used to record this in their medical history.
Documentation should clearly state the type of benign neoplasm, the date of diagnosis or removal (if applicable), and any relevant treatment received. Pathology reports or prior medical records can be helpful supporting documentation.
** Excludes2: personal history of malignant neoplasms (Z85.-). Code first any follow-up examination after treatment (Z09).
- Specialties:Any specialty can potentially use this code as it pertains to documenting a patient's past medical history. Specialties that frequently encounter benign neoplasms include dermatology, oncology, gynecology, gastroenterology, and general surgery.
- Place of Service:Any