2025 ICD-10-CM code Z91.52
(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 nonsuicidal self-harm.This code indicates a past instance of self-harm without suicidal intent.
Modifiers are not applicable to ICD-10 codes.
The medical necessity of coding Z91.52 lies in its potential impact on current healthcare management.The history of nonsuicidal self-harm can provide valuable insights into the patient's mental health, risk factors, and overall treatment plan. It highlights the need for continued monitoring or ongoing support.
The clinical responsibility involves documenting the patient's history of nonsuicidal self-harm accurately.This might involve reviewing past medical records, conducting interviews with the patient, and assessing the potential impact of this history on current treatment or management. The physician needs to determine if there's any current mental health concern or if it's simply part of the patient's history.
- Chapter 21: Factors influencing health status and contact with health services
- Z91.52 is under the broader category Z91.5 (Personal history of self-harm), which in turn falls under Chapter 21 (Factors influencing health status and contact with health services).
In simple words: This code means the person has hurt themselves in the past, but they didn't want to die. It's a way to track this history, even if it's not a problem right now.Doctors might use this if the past self-harm could affect how they treat the person now.
Z91.52, Personal history of nonsuicidal self-harm, is an ICD-10-CM code used to document a patient's history of self-inflicted injury where there was no intent to die.This code is used when the self-harm is no longer an active condition but has the potential for recurrence and may influence current treatment or management.It encompasses various forms of self-harm, such as self-cutting, burning, or other deliberate self-inflicted injuries without suicidal ideation.The code should be used in conjunction with other relevant codes to fully describe the patient's condition and the reason for the current encounter.
Example 1: A 25-year-old female presents for a routine physical examination. During the interview, she discloses a history of self-cutting in adolescence but reports no current suicidal ideation or self-harm behavior.Z91.52 would be coded., A 30-year-old male is being treated for anxiety and depression.He reports a history of self-harm without suicidal intent several years prior.This history is relevant to his current mental health management, and Z91.52 is coded along with codes for his current diagnoses and treatments., A 17-year-old presents to the emergency department following a self-inflicted burn.After a thorough evaluation, it's determined that the self-harm was not a suicide attempt; rather it was a reaction to stressful life events. Treatment was provided for the burn, butthere was no suicidal ideation.While R45.88 (current nonsuicidal self-injury) would be more appropriate at the time of the event, Z91.52 could be applied in a subsequent visit to document the history and its potential relevance.
Documentation should include a clear statement indicating the absence of suicidal intent at the time of the self-harm.Details about the method of self-harm, the date of the event(s), and any prior treatment or counseling related to it should be included. If a mental health disorder is suspected, the diagnosis should be properly documented.Any relevant notes from previous encounters should also be referenced.
** While Z91.52 is used for past events, it's crucial to differentiate it from current self-harm.For current self-harm, consider using appropriate R or T codes depending on the context.Always ensure complete and accurate documentation to support the code.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Specialties:Psychiatry, Psychology, General Practice, Emergency Medicine
- Place of Service:Office, Hospital (Inpatient or Outpatient), Emergency Room, Mental Health Facility