2025 ICD-10-CM code Z30.41
Encounter for surveillance of contraceptive pills. This includes encounters for repeat prescriptions.
Medical necessity for this code is established when the encounter is for the purpose of monitoring the patient's ongoing use of contraceptive pills, addressing any concerns or side effects, or providing refills for continued use.
The provider is responsible for monitoring the patient's use of contraceptive pills, discussing any concerns or side effects, and providing refills as needed.
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- Persons encountering health services in circumstances related to reproduction (Z30-Z3A)
In simple words: A visit to a healthcare provider for monitoring the use of birth control pills or getting a refill.
Encounter for surveillance of contraceptive pills. This includes encounters for repeat prescriptions.
Example 1: A patient has been taking birth control pills for six months and comes in for a routine follow-up appointment to discuss any side effects and obtain a refill., A patient is experiencing breakthrough bleeding while on the pill and schedules an appointment to discuss alternative options or management strategies., A patient has recently started taking a new brand of birth control pills and schedules a follow-up to ensure the medication is well-tolerated and effective.
The medical record should document the type of contraceptive pill being used, any side effects experienced, the reason for the encounter (e.g., routine surveillance, concern about side effects), and any changes to the prescription or management plan.