2025 ICD-10-CM code Z91.A
(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) 21. Factors influencing health status and contact with health services (Z00-Z99) Feed
Caregiver's noncompliance with patient's medical treatment and regimen.
The medical necessity for using this code is established when a caregiver's noncompliance with a patient’s medical treatment plan is impacting the patient’s health or treatment outcomes.
It is the clinician's responsibility to document the caregiver's noncompliance and its impact on the patient's health status.This includes specifying the type of noncompliance, such as medication underdosing, non-adherence to dietary restrictions, or missed therapy appointments.
- 21. Factors influencing health status and contact with health services (Z00-Z99)
- Persons with potential health hazards related to family and personalhistory and certain conditions influencing health status (Z77-Z99)
In simple words: This code is used when a person caring for a patient isn't following the doctor's orders for the patient's treatment.
This code is used when a caregiver is not complying with a patient's prescribed medical treatment plan, which can include medication, diet, therapy, or other prescribed regimens. This noncompliance can be intentional or unintentional.
Example 1: A child's caregiver intentionally reduces the dosage of a prescribed medication due to financial hardship, potentially compromising the child's treatment., An elderly patient's caregiver unintentionally misses doses of prescribed medication due to forgetfulness or misunderstanding of instructions, leading to a decline in the patient's condition., The caregiver of a patient with dietary restrictions consistently prepares meals that do not adhere to the prescribed diet, negatively impacting the patient's health.
Documentation should clearly state the specific areas of noncompliance, the reasons for noncompliance (if known), and the impact of noncompliance on the patient’s health. Any communication with the caregiver regarding the noncompliance should also be documented.
** Excludes2: contact with and (suspected) exposures hazardous to health (Z77.-) exposure to pollution and other problems related to physical environment (Z77.1-) female genital mutilation status (N90.81-) occupational exposure to risk factors (Z57.-) personal history of physical injury and trauma (Z87.81, Z87.82-)It’s crucial to distinguish between caregiver noncompliance and patient noncompliance (Z91.1-) when selecting the appropriate code.This code helps to provide a more complete picture of the factors influencing a patient's health status and can be valuable information for care management and coordination.
- Specialties:Any specialty involved in patient care where a caregiver is responsible for administering or overseeing treatment can use this code. This might include Pediatrics, Geriatrics, Family Medicine, Internal Medicine, and various surgical specialties.
- Place of Service:Any place of service where the patient is receiving care and the caregiver is responsible for treatment adherence.