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BETA v.3.0

2025 ICD-10-CM code Z30.42

Encounter for surveillance of injectable contraceptive.

A corresponding procedure code must accompany a Z code if a procedure is performed during the encounter.If the encounter is solely for surveillance and no procedure is performed, the Z code alone is sufficient.This code should not be used for the initial prescription of injectable contraception.

Medical necessity for this encounter is established by the patient's need for ongoing monitoring and management of their contraceptive method to ensure its safety and effectiveness.

The healthcare provider is responsible for evaluating the patient's current contraceptive method, addressing any concerns, and ensuring its continued suitability and effectiveness. This may involve physical examination, counseling, and prescribing refills or alternative methods as needed.

In simple words: The patient had a check-up related to their birth control injection.

The patient encountered a healthcare professional for surveillance of their injectable contraceptive. This includes monitoring the effectiveness, managing potential side effects, and discussing continuation or alternative methods.

Example 1: A patient has been using injectable contraception for six months and visits their healthcare provider for a follow-up appointment to discuss its effectiveness and any side effects., A patient experiences irregular bleeding while using injectable contraception and seeks medical advice to determine the cause and discuss management options., A patient wishes to switch from injectable contraception to another method and consults with their doctor to explore available alternatives and receive appropriate guidance.

Documentation should include the type of injectable contraceptive being used, date of last injection, any reported side effects, examination findings, and any changes made to the contraceptive plan.

** Use of this code indicates that the patient is currently using an injectable contraceptive and is seeking surveillance, not initial prescription or insertion. It is crucial to accurately document the specific type of contraceptive being monitored.

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