2025 ICD-10-CM code Z91.15
(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 21. Factors influencing health status and contact with health services (Z00-Z99) Feed
Patient's noncompliance with renal dialysis.
Medical necessity for other services related to complications arising from noncompliance should be documented. For example, if a patient experiences complications due to missed dialysis sessions, the medical necessity of treating those complications should be supported with appropriate documentation.
The physician is responsible for documenting the patient's noncompliance and educating the patient about the importance of adherence to the dialysis regimen.
- 21. Factors influencing health status and contact with health services (Z00-Z99)
- Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99)
In simple words: The patient is not following their kidney dialysis treatment plan.
This code indicates that the patient is not adhering to the prescribed renal dialysis regimen.
Example 1: A patient with end-stage renal disease (ESRD) misses multiple dialysis appointments and reports feeling unwell. The physician documents the patient's noncompliance with renal dialysis and explains the risks of missing treatments., A patient with ESRD consistently arrives late for dialysis sessions and shortens treatment times due to other commitments. The nephrologist documents the patient's noncompliance and encourages adherence to the prescribed schedule., A patient with ESRD refuses to follow dietary restrictions and fluid intake guidelines prescribed as part of the dialysis treatment plan. The physician documents the noncompliance and educates the patient about the potential complications.
Documentation should clearly indicate the patient's non-adherence to the prescribed renal dialysis plan, including missed appointments, shortened treatment times, or non-compliance with dietary and fluid restrictions. The reason for noncompliance, if known, should also be documented.
** For accurate coding, it's essential to differentiate between dependence on renal dialysis (Z99.2) and noncompliance with it (Z91.15). Z99.2 is used to indicate ongoing dependence on dialysis, while Z91.15 signifies non-adherence to the treatment plan.
- Specialties:Nephrology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Independent Clinic, Federally Qualified Health Center, End-Stage Renal Disease Treatment Facility, Public Health Clinic, Rural Health Clinic, Office, and other places of service where dialysis is provided or discussed with the patient.