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v1.0.0
ICD-10 Guide
ICD-10 CodesZ36.2

Z36.2

Encounter for other antenatal screening follow-up

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

Code Description

ICD-10 Z36.2 is a billable code used to indicate a diagnosis of encounter for other antenatal screening follow-up.

Key Diagnostic Point:

Z36.2 is utilized during encounters for follow-up related to antenatal screening that does not fall under the standard categories of screening tests. This code is essential for tracking the health status of pregnant individuals and ensuring that any potential risks identified during initial screenings are monitored and managed appropriately. Factors influencing health status include socioeconomic status, access to healthcare, education, and support systems, which can significantly affect maternal and fetal outcomes. Preventive care in this context involves regular follow-ups to assess the effectiveness of interventions, monitor for complications, and provide education on health behaviors. Screening may include assessments for gestational diabetes, hypertension, and other conditions that could impact pregnancy. Aftercare is crucial for addressing any issues that arise from screenings, ensuring that patients receive the necessary referrals and follow-up care. Accurate documentation of these encounters is vital for quality care and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of antenatal screenings that may be included under this code
  • Need for comprehensive documentation of follow-up findings
  • Potential overlap with other Z codes related to antenatal care
  • Variability in payer requirements for coverage of follow-up screenings

Audit Risk Factors

  • Inadequate documentation of the specific screening performed
  • Failure to link follow-up encounters to initial screening results
  • Lack of evidence for medical necessity in follow-up visits
  • Misuse of Z36.2 when a more specific Z code is applicable

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of the screening performed, results, and any follow-up actions taken. It should also reflect the patient's health status and any interventions initiated.

Common Clinical Scenarios

Routine checkups for pregnant patients, follow-up visits after abnormal screening results, and education on lifestyle modifications.

Billing Considerations

Consideration of social determinants such as access to transportation for follow-up visits, support systems, and education level impacting health literacy.

Public Health

Documentation Requirements

Documentation should focus on population-level data, including screening rates, follow-up compliance, and health outcomes.

Common Clinical Scenarios

Community health initiatives aimed at improving maternal health, tracking epidemiological trends in antenatal care.

Billing Considerations

Emphasis on health equity and addressing barriers to care in underserved populations.

Coding Guidelines

Inclusion Criteria

Use Z36.2 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 following a primary diagnosis related to pregnancy
  • Payer requirements may vary, so it is essential to verify coverage for follow
  • up screenings

Exclusion Criteria

Do NOT use Z36.2 When
No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for follow-up visits after antenatal screenings.

Documentation Requirements

Document the reason for the visit, findings from the screening, and any interventions.

Specialty Considerations

Primary care providers should ensure comprehensive documentation of the patient's health status.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding antenatal care, enabling better tracking of maternal health outcomes and the effectiveness of preventive measures.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding antenatal care, enabling better tracking of maternal health outcomes and the effectiveness of preventive measures.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding antenatal care, enabling better tracking of maternal health outcomes and the effectiveness of preventive measures.

Resources

Clinical References

  • •
    CDC Maternal and Infant Health

Coding & Billing References

  • •
    CDC Maternal and Infant Health

Frequently Asked Questions

When should Z36.2 be used?

Z36.2 should be used for follow-up encounters related to antenatal screenings that do not fall under specific categories like genetic or infectious disease screenings. It is essential to document the reason for the follow-up and any findings from the initial screening.