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ICD-10 Guide
ICD-10 CodesZ01.118

Z01.118

Encounter for examination of ears and hearing with other abnormal findings

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

Code Description

ICD-10 Z01.118 is a billable code used to indicate a diagnosis of encounter for examination of ears and hearing with other abnormal findings.

Key Diagnostic Point:

Z01.118 is used for encounters where patients undergo examinations of the ears and hearing, revealing abnormal findings that may not be directly related to a specific disease. This code is particularly relevant in preventive care settings where early detection of hearing issues is crucial. Factors influencing health status, such as socioeconomic status, access to healthcare, and environmental factors, play a significant role in the prevalence of hearing disorders. Social determinants of health, including education level and community resources, can impact a patient's likelihood of seeking preventive screenings. This code is often utilized in routine checkups, where audiometric tests may reveal abnormalities, prompting further investigation or referral. Preventive care and screening are essential to identify potential hearing loss early, allowing for timely intervention and management. Aftercare may involve follow-up appointments to monitor the patient's hearing status and address any ongoing concerns.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Documentation of abnormal findings must be specific and detailed.
  • Requires understanding of the relationship between findings and potential interventions.
  • May involve multiple specialties for comprehensive care.
  • Need for accurate coding to reflect the reason for the encounter.

Audit Risk Factors

  • Inadequate documentation of abnormal findings.
  • Failure to link findings to the reason for the encounter.
  • Misuse of the code for routine examinations without abnormalities.
  • Inconsistent coding practices among different providers.

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation must include specific abnormal findings, rationale for the examination, and any follow-up plans.

Common Clinical Scenarios

Routine checkups where hearing issues are assessed, screenings for hearing loss in at-risk populations.

Billing Considerations

Consideration of social determinants such as access to care and patient education on hearing health.

Public Health

Documentation Requirements

Population-level data collection, including demographics and prevalence of hearing issues.

Common Clinical Scenarios

Community screenings for hearing loss, epidemiological studies on hearing health.

Billing Considerations

Focus on health disparities and access to preventive services.

Coding Guidelines

Inclusion Criteria

Use Z01.118 When
  • Z codes are used when a patient encounters a healthcare provider for reasons other than a specific illness or injury
  • 118 should be sequenced appropriately, often as a secondary code following a primary diagnosis
  • Payer requirements may vary, so it's essential to verify coverage for preventive services

Exclusion Criteria

Do NOT use Z01.118 When
No specific exclusions found.

Related CPT Codes

92551CPT Code

Screening test for hearing loss

Clinical Scenario

Used during routine checkups or screenings where Z01.118 is applicable.

Documentation Requirements

Document the reason for the screening and any abnormal findings.

Specialty Considerations

Primary care providers should ensure comprehensive documentation to support the use of Z01.118.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding, particularly for encounters like Z01.118, which captures the nuances of abnormal findings in hearing examinations.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding, particularly for encounters like Z01.118, which captures the nuances of abnormal findings in hearing examinations.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    CDC Hearing Loss Prevention

Coding & Billing References

  • •
    CDC Hearing Loss Prevention

Frequently Asked Questions

When should Z01.118 be used instead of Z01.119?

Z01.118 should be used when abnormal findings are documented during an ear and hearing examination, indicating the need for further evaluation or intervention. Z01.119 is appropriate when no abnormalities are found.