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2025 ICD-10-CM code Z30.44

Encounter for surveillance of vaginal ring hormonal contraceptive device.

Follow current ICD-10-CM coding guidelines and conventions as published by the Centers for Medicare & Medicaid Services (CMS).

Modifiers are not applicable to ICD-10 codes.

Medical necessity is established by the need to monitor the patient's health and the effectiveness of the hormonal contraceptive method to ensure patient safety and prevent potential complications. Regular surveillance is considered best practice for maintaining optimal contraceptive efficacy and patient well-being. The frequency of surveillance may vary based on individual patient needs and clinical judgment.

The clinical responsibility lies with the physician or healthcare professional conducting the surveillance visit. This involves reviewing the patient's history, performing a physical exam (as needed), addressing any concerns, and ensuring the contraceptive method remains effective and safe for the patient.The responsibility also extends to counseling the patient about proper use and potential side effects.

IMPORTANT:Related codes include Z30.45 (transdermal patch) and Z30.46 (implantable subdermal contraceptive).If a procedure is performed during the surveillance visit, an appropriate procedural code must also be used.

In simple words: This code is used when someone goes to the doctor for a checkup related to their vaginal ring birth control. The visit is to make sure the birth control is working correctly and the person is healthy.

This ICD-10-CM code signifies a healthcare encounter specifically for monitoring and assessing a patient using a vaginal ring hormonal contraceptive device.The encounter focuses on the surveillance of the device's effectiveness and the patient's overall health in relation to its use.It does not include the initial prescription or insertion of the device.

Example 1: A 30-year-old female patient returns for a routine three-month check-up related to her NuvaRing hormonal contraceptive. The physician reviews her medical history, performs a brief physical exam, and addresses any questions or concerns she may have.No complications are identified., A 25-year-old female patient presents for a follow-up visit after experiencing unexpected spotting while using a vaginal ring. The physician reviews the patient’s history, orders lab work to rule out other issues, and advises the patient on managing the spotting., A 35-year-old female patient reports having difficulty inserting or removing her vaginal ring. The physician provides counseling and instruction on proper insertion and removal techniques.

Documentation should include the patient's reason for the visit (surveillance of vaginal ring), the date of the last visit (if applicable), a description of any symptoms or concerns reported by the patient, the results of any physical examination or tests, the physician's assessment of the patient's health status, and any counseling or instruction provided.

** This code should only be used for surveillance visits related to vaginal ring hormonal contraceptives.It should not be used for the initial prescription or insertion of the device.

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