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v1.0.0
ICD-10 Guide
ICD-10 CodesZ30.2

Z30.2

Billable

Encounter for sterilization

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 Z30.2 is a billable code used to indicate a diagnosis of encounter for sterilization.

Key Diagnostic Point:

Z30.2 is used to indicate an encounter for sterilization, a procedure aimed at permanent contraception. This code is relevant in contexts where patients seek to prevent future pregnancies due to personal, medical, or socio-economic reasons. Factors influencing the decision for sterilization may include age, number of children, health conditions, and socio-economic status. Preventive care in this context involves counseling about reproductive health, family planning options, and the implications of sterilization. Screening for potential health risks associated with the procedure, such as psychological readiness and understanding of the permanence of the decision, is also essential. Social determinants of health, such as access to healthcare services, education level, and cultural beliefs, play a significant role in a patient's decision-making process regarding sterilization. Proper documentation of the patient's informed consent, counseling provided, and any relevant medical history is crucial for accurate coding and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for thorough documentation of informed consent
  • Assessment of patient understanding of the procedure
  • Potential co-existing conditions that may affect the procedure
  • Variability in payer requirements for sterilization procedures

Audit Risk Factors

  • Inadequate documentation of informed consent
  • Failure to document counseling provided to the patient
  • Lack of clarity on the patient's understanding of the procedure
  • Incorrect sequencing of codes related to sterilization

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation must include patient history, counseling details, and informed consent.

Common Clinical Scenarios

Routine checkups where sterilization is discussed, follow-up visits post-procedure.

Billing Considerations

Consideration of social determinants such as access to contraception and education on reproductive health.

Public Health

Documentation Requirements

Documentation should include population health data and surveillance of sterilization trends.

Common Clinical Scenarios

Community health initiatives promoting family planning and reproductive health education.

Billing Considerations

Focus on health equity and access to sterilization services across different populations.

Coding Guidelines

Inclusion Criteria

Use Z30.2 When
  • Z codes are used when a patient encounters healthcare services for reasons other than a current illness or injury
  • 2 should be sequenced appropriately, often as a primary diagnosis when the encounter is specifically for sterilization
  • Payer requirements may vary, so it is essential to verify coverage for sterilization procedures

Exclusion Criteria

Do NOT use Z30.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58600CPT Code

Laparoscopic sterilization

Clinical Scenario

Used when a patient undergoes laparoscopic sterilization, often coded with Z30.2.

Documentation Requirements

Documentation must include the procedure performed, patient consent, and any pre-operative assessments.

Specialty Considerations

Primary care providers should ensure comprehensive counseling is documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding encounters for sterilization, improving data accuracy and facilitating better tracking of reproductive health services.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding encounters for sterilization, improving data accuracy and facilitating better tracking of reproductive health services.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding encounters for sterilization, improving data accuracy and facilitating better tracking of reproductive health services.

Resources

Clinical References

  • •
    CDC Family Planning Guidelines

Coding & Billing References

  • •
    CDC Family Planning Guidelines

Frequently Asked Questions

What documentation is required for Z30.2?

Documentation must include patient history, details of counseling provided, informed consent, and any relevant medical assessments to support the decision for sterilization.