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2025 ICD-10-CM code Z71.6

Tobacco abuse counseling; this code is used when a patient receives counseling related to tobacco use.

Always use the most specific code that accurately reflects the service provided.This code should only be used when counseling is the primary service provided.

Medical necessity is established by the patient's tobacco use history, the presence of tobacco-related illness or risk factors, and the demonstrable need for counseling to aid in cessation or management of tobacco use. The counseling should be provided by a qualified professional.

The clinical responsibility lies with healthcare professionals, such as physicians, nurses, or counselors, who provide counseling services related to tobacco cessation.

IMPORTANT:Consider using additional codes for nicotine dependence (F17.-) if applicable.Excludes codes for contraceptive or procreation counseling (Z30-Z31) and sex counseling (Z70.-).

In simple words: This code means the person went to a doctor or healthcare provider to get advice and help with quitting or dealing with tobacco use.

This ICD-10-CM code, Z71.6, signifies a patient encounter for tobacco abuse counseling.It's applied when a patient seeks guidance and support for quitting or managing tobacco use.This code should not be used if the patient is undergoing tobacco rehabilitation procedures; those instances warrant a different code from the Z50 category.A procedure code must accompany Z71.6 if any procedures are performed during the encounter.

Example 1: A 45-year-old patient with a 20-pack-year smoking history seeks counseling to quit smoking.The session includes motivational interviewing, discussion of cessation aids, and development of a personalized quit plan., A pregnant woman receives counseling on the dangers of smoking during pregnancy and is given resources for cessation support., A patient with chronic obstructive pulmonary disease (COPD) attends a counseling session focused on managing their condition and quitting smoking to improve respiratory health.

Documentation should include the patient's tobacco use history, the type of counseling provided (individual, group, etc.), the duration of the session, the counseling techniques used, and the patient's response to the counseling.Any resources provided, including cessation aids or referrals, should also be documented.

** This code is used for tobacco use counseling only.Other codes exist for nicotine dependence or treatment of nicotine dependence.Appropriate documentation supporting the medical necessity for the counseling session must be present.

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