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v1.0.0
ICD-10 Guide
ICD-10 CodesZ36.4

Z36.4

Encounter for antenatal screening for fetal growth retardation

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

Code Description

ICD-10 Z36.4 is a billable code used to indicate a diagnosis of encounter for antenatal screening for fetal growth retardation.

Key Diagnostic Point:

Z36.4 is used to indicate an encounter for antenatal screening specifically aimed at identifying fetal growth retardation. This screening is crucial as it allows healthcare providers to monitor fetal development and intervene early if growth issues are detected. Factors influencing health status, such as maternal nutrition, socioeconomic status, and access to healthcare services, play a significant role in fetal growth. Social determinants of health, including education level, income, and community resources, can affect a mother's ability to maintain a healthy pregnancy. Preventive care through regular screenings can help mitigate risks associated with fetal growth retardation, ensuring better outcomes for both mother and child. This code is essential for tracking health trends and ensuring that at-risk populations receive appropriate care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for accurate documentation of maternal health history
  • Variability in screening protocols across different healthcare settings
  • Potential overlap with other Z codes related to antenatal care
  • Importance of capturing social determinants of health in documentation

Audit Risk Factors

  • Inadequate documentation of maternal health history
  • Failure to document follow-up actions based on screening results
  • Misuse of Z36.4 when other conditions are present
  • Lack of clarity in linking social determinants to health outcomes

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include maternal health history, screening results, and any interventions planned or taken.

Common Clinical Scenarios

Routine prenatal visits where fetal growth is assessed, and follow-up care is planned based on screening outcomes.

Billing Considerations

Consideration of social determinants such as access to nutrition and prenatal care services.

Public Health

Documentation Requirements

Documentation should focus on population health data, screening rates, and outcomes related to fetal growth retardation.

Common Clinical Scenarios

Community health initiatives aimed at improving maternal and fetal health through targeted screening programs.

Billing Considerations

Emphasis on tracking health disparities and access to care in different populations.

Coding Guidelines

Inclusion Criteria

Use Z36.4 When
  • Z codes are used when a patient encounters healthcare services for reasons other than a specific illness or injury
  • 4 should be sequenced appropriately, often as a secondary code following a primary diagnosis related to pregnancy
  • Payer requirements may vary, so it's essential to check specific guidelines for coverage of screening services

Exclusion Criteria

Do NOT use Z36.4 When
No specific exclusions found.

Related CPT Codes

76801CPT Code

Ultrasound, pregnant uterus, transabdominal, real-time with image documentation

Clinical Scenario

Used during routine prenatal visits to assess fetal growth and development.

Documentation Requirements

Documentation of ultrasound findings and any follow-up actions taken.

Specialty Considerations

Primary care providers should ensure that ultrasound results are clearly linked to Z36.4.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding antenatal screenings, improving the ability to track and address fetal growth issues effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding antenatal screenings, improving the ability to track and address fetal growth issues effectively.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding antenatal screenings, improving the ability to track and address fetal growth issues effectively.

Resources

Clinical References

  • •
    CDC Guidelines on Antenatal Care

Coding & Billing References

  • •
    CDC Guidelines on Antenatal Care

Frequently Asked Questions

When should Z36.4 be used?

Z36.4 should be used during encounters specifically for antenatal screening for fetal growth retardation, particularly when maternal health factors are assessed.