2025 ICD-10-CM code Z86.0
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status - Personal history of certain other diseases Factors influencing health status and contact with health services Feed
Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior.
The medical necessity for coding Z86.0 is based on the completeness and accuracy of the patient's medical history.This code is used to provide a comprehensive record of past medical events and doesn't represent a current medical need for treatment. The clinical documentation must justify the inclusion of this code.
Documentation of the patient's history of benign or in-situ neoplasms. This is primarily the responsibility of the physician or healthcare provider obtaining the patient's history.The coder verifies that the documentation supports the use of this code.
- Factors influencing health status and contact with health services
- Z86.0 falls under the broader category of Z codes (Factors influencing health status and contact with health services) and specifically within the subcategory of personal history of certain other diseases (Z86).
In simple words: This code means the person has a past medical record of non-cancerous growths or tumors that were not invasive or spread to other parts of the body.This is not a current problem but is part of their medical history.
This ICD-10-CM code signifies a documented history of in-situ (non-invasive) neoplasms, benign neoplasms, or neoplasms of uncertain or unknown behavior.It indicates a past occurrence of these types of tumors that did not metastasize or display malignant characteristics.The code is used for documentation purposes when the neoplasm is not currently active and does not require active treatment.It is crucial to differentiate this from a history of malignant neoplasms (coded separately under Z85.-).
Example 1: A 60-year-old female patient presents for a routine check-up.Her medical history reveals a prior excision of a benign skin lesion 10 years ago.Z86.0 is coded to reflect this past event., A 45-year-old male patient is undergoing a pre-operative evaluation for a planned procedure.His medical records indicate a previous diagnosis of a uterine fibroid that was surgically removed five years prior.The code Z86.0 is used to reflect the personal history., A 30 year old patient presents to the clinic with complaints of abdominal pain. The patient had a history of a benign ovarian cyst that had resolved without surgical intervention several years ago. The physician documents that the resolved cyst is unrelated to the current abdominal pain. Z86.0 would be used in this scenario.
Complete medical history including details about the type of neoplasm, the date of diagnosis or treatment, and evidence confirming its benign nature or in-situ status. Pathology reports or radiology images may be necessary for verification.
** This code is used in conjunction with other codes to provide a complete clinical picture.Always refer to the most recent ICD-10-CM coding guidelines for the most accurate coding practices.The absence of malignant characteristics is a critical element in applying Z86.0.
- Payment Status: Active
- Specialties:Oncology, Family Medicine, Internal Medicine, Surgery
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital