2025 ICD-10-CM code Z86.010
(Active) Effective Date: N/A Revision 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 Chapter 21: Factors influencing health status and contact with health services Feed
Personal history of colonic polyps.
Modifiers are not applicable to ICD-10 diagnosis codes.
Medical necessity for coding Z86.010 is established when a patient's history of colonic polyps is relevant to their current medical care. This is typically the case for patients requiring surveillance for recurrence or for those with known risk factors for developing colorectal cancer.
The clinical responsibility for this code involves documenting the patient's history of colonic polyps, including the type of polyps, date of diagnosis, treatment received, and any follow-up care.The physician may also order further tests or procedures, such as colonoscopy, based on the patient's risk profile.
- Chapter 21: Factors influencing health status and contact with health services
- Z86.010 is under Z86.0 (Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior), which falls within the broader category Z86 (Personal history of certain other diseases). This is in Chapter 21.
In simple words: This code is used when someone has had colon polyps (small growths) found in their colon in the past.It's used for check-ups or other visits focused on managing the person's history of having polyps, not for a current problem.
This code signifies a documented history of benign or non-malignant colon polyps.It indicates a past diagnosis of polyps in the colon, irrespective of whether they were removed or treated. This code is used for encounters focused on managing or monitoring the patient's history, rather than an acute episode of polyps.
Example 1: A 55-year-old patient presents for a routine checkup.Medical records reveal a history of adenomatous colon polyps removed 3 years prior. Code Z86.010 is used to document this personal history as a factor influencing the patient's current health status., A 60-year-old patient is scheduled for a colonoscopy. The patient has a documented history of hyperplastic polyps found during a previous colonoscopy 5 years ago. Code Z86.010 is used to document this pre-existing condition, along with appropriate procedural codes for the new colonoscopy., A 70-year-old patient is referred to a gastroenterologist for ongoing surveillance following a previous colonoscopy that revealed a history of multiple colon polyps. Z86.010 is used to document the patient's history along with any other relevant codes reflecting the reason for the visit and any other procedures.
Documentation should include the date of the previous diagnosis, type of polyp(s) identified (e.g., adenomatous, hyperplastic), location in the colon, details of previous treatment (if any), and any associated imaging reports.The physician's documentation should clarify the reason for the current encounter in relation to the patient's history of colonic polyps.
** Z86.010 is used for a personal history, not for active disease.If the patient has a current diagnosis of colonic polyps or colorectal cancer, other more appropriate codes should be used. This code should be used in conjunction with other codes as clinically indicated.
- Payment Status: Active
- Modifier TC rule: Not applicable to diagnosis codes.
- Specialties:Gastroenterology, Colorectal Surgery, General Surgery, Oncology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center