2025 ICD-10-CM code Z91.1
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status 21. Factors influencing health status and contact with health services (Z00-Z99) Feed
Patient's noncompliance with medical treatment and regimen. This includes instances where a patient does not adhere to prescribed medications, therapies, or follow-up appointments.
Medical necessity is established by demonstrating the negative impact of noncompliance on the patient’s health. This might include worsening symptoms, disease progression, or development of complications.
Clinicians should clearly document the specific ways in which the patient is noncompliant, including the prescribed treatment, the patient's actions, and any counseling or education provided. The impact of noncompliance on the patient's health should also be noted.It is crucial to understand the reasons for noncompliance, as they can range from financial hardship and medication side effects to cognitive impairment and lack of understanding.
- 21. Factors influencing health status and contact with health services (Z00-Z99)
- Z91. Personal risk factors, not elsewhere classified
In simple words: This code indicates that the patient isn't following their doctor's orders, like not taking their medicine correctly or skipping appointments.
This code signifies a patient's failure to comply with a prescribed medical treatment plan or regimen.Noncompliance can manifest in various forms, such as neglecting to take medications as instructed (including incorrect dosage or frequency), missing scheduled appointments for therapies or follow-up examinations, or disregarding other prescribed care instructions.This code is used to document this non-adherence, which may have implications for the patient's health outcomes and management of their condition.
Example 1: A patient with diabetes consistently misses insulin injections and does not follow the prescribed diet., A patient with hypertension forgets to take their medication regularly, leading to uncontrolled blood pressure., A patient undergoing chemotherapy frequently cancels or reschedules treatment sessions.
Detailed documentation of the prescribed treatment plan and the patient’s specific non-adherent behaviors is necessary. This should include dates and times of missed medications, appointments, or other prescribed activities, as well as any attempts made to educate or counsel the patient about the importance of adherence.
** It's important to differentiate between intentional and unintentional noncompliance, as this can affect treatment decisions and patient education strategies.If the noncompliance is due to financial hardship or other social determinants of health, appropriate referrals and support services should be provided.
- Specialties:The use of this code is relevant to all medical specialties that provide ongoing treatment and management for medical conditions.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Home Health, Nursing Facility