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BETA v.3.0

2025 ICD-10-CM code Z30.41

Encounter for surveillance of contraceptive pills. This includes encounters for repeat prescriptions.

A corresponding procedure code must accompany a Z code if a procedure is performed. If the encounter is for the insertion, removal, or checking of a contraceptive device, a different Z code should be used (Z30.43).

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.

IMPORTANT:Z30.4: Encounter for surveillance of contraceptivesZ30.40: Encounter for surveillance of contraceptives, unspecifiedZ30.42: Encounter for surveillance of injectable contraceptiveZ30.43: Encounter for surveillance of intrauterine contraceptive deviceZ30.44: Encounter for surveillance of vaginal ring hormonal contraceptive deviceZ30.45: Encounter for surveillance of transdermal patch hormonal contraceptive deviceZ30.46: Encounter for surveillance of implantable subdermal contraceptiveZ30.49: Encounter for surveillance of other contraceptivesZ79.3: Long term (current) use of hormonal contraceptives

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.

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