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2025 ICD-10-CM code Z30.011

Encounter for initial prescription of contraceptive pills.

A corresponding procedure code must accompany a Z code if a procedure is performed. Use Z codes only when circumstances other than a disease, injury, or external cause are the reason for the encounter. Do not use Z30.011 for follow-up visits related to contraceptive management; use Z30.4- instead.

The prescription of contraceptive pills is medically necessary for preventing pregnancy in sexually active females who desire to avoid pregnancy.

The healthcare provider is responsible for evaluating the patient's medical history, discussing various contraceptive options, prescribing the appropriate contraceptive pills, and providing education on their use and potential side effects.

In simple words: This code is used when a patient visits a healthcare professional for the first time to get a prescription for birth control pills.

Encounter for initial prescription of contraceptive pills.This code excludes encounters for surveillance of contraceptives (Z30.4-).

Example 1: A 25-year-old female visits her physician for the first time to discuss birth control options. After reviewing her medical history and discussing the risks and benefits of various methods, the physician prescribes combined oral contraceptive pills. The code Z30.011 is used., An 18-year-old female visits a family planning clinic seeking contraception. She requests birth control pills and is counseled on their use. The clinician prescribes her a pack of pills and provides instructions. The code Z30.011 is reported., A 30-year-old female who has been using condoms for contraception decides to switch to birth control pills. She consults her gynecologist, who prescribes her a suitable pill after a thorough examination. Z30.011 is the correct code to use in this scenario.

The medical record should document the patient's request for contraception, medical history review, discussion of contraceptive options, the type of contraceptive pill prescribed, instructions given to the patient, and any relevant education provided.

** This code is specifically for the initial prescription of contraceptive pills and should not be used for other contraceptive methods or follow-up visits.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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