ICD-10-CM Code Z53.20

Procedure and treatment not carried out because of patient's decision for unspecified reasons

Version 2020 Billable Code Unacceptable Principal Diagnosis

Valid for Submission

Z53.20 is a billable code used to specify a medical diagnosis of procedure and treatment not carried out because of patient's decision for unspecified reasons. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Z53.20 might also be used to specify conditions or terms like 10 year examination not wanted, 15 year examination not wanted, 18 month examination not wanted, 2.5 year examination not wanted, 3.5 year examination not wanted, 4.5 year examination not wanted, etc

The code Z53.20 describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.

ICD-10:Z53.20
Short Description:Proc/trtmt not crd out bec pt decision for unsp reasons
Long Description:Procedure and treatment not carried out because of patient's decision for unspecified reasons

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code Z53.20 are found in the index:


Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:

  • Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • 10 year examination not wanted
  • 15 year examination not wanted
  • 18 month examination not wanted
  • 2.5 year examination not wanted
  • 3.5 year examination not wanted
  • 4.5 year examination not wanted
  • 8-9 month exam not wanted
  • A/N amniocentesis - not wanted
  • A/N U/S scan not wanted
  • Abdominal aortic aneurysm screening declined
  • Administration of blood product declined
  • Administration of RhD immune globulin refused
  • Adult health examination refused
  • Advance care planning declined
  • AFP blood test not wanted
  • Alcohol brief intervention refused
  • Alcohol consumption screening test declined
  • Ambulance transport to hospital declined
  • Anal examination declined
  • Anal Papanicolaou smear declined
  • Angiocardiography declined
  • Angiotensin converting enzyme inhibitor declined
  • Angiotensin II receptor antagonist declined
  • Ankle brachial pressure index test declined
  • Antenatal care: not attended
  • Antenatal care: not wanted
  • Antenatal screening declined
  • Antenatal screening for Down syndrome declined
  • Antenatal screening for Down, Edwards and Patau syndromes declined
  • Antenatal screening for Edwards and Patau syndromes declined
  • Antenatal screening for human immunodeficiency virus refused
  • Antenatal screening for viral hepatitis type B refused
  • Antenatal thalassemia screening refused
  • Anticoagulation declined
  • Antineoplastic chemotherapy regimen declined
  • Antiviral therapy declined
  • Aspirin prophylaxis refused
  • Assessment examination refused
  • Assessment of physical health declined
  • Asthma monitoring refused
  • Beta blocker therapy refused
  • Bisphosphonates declined
  • Blood glucose test declined
  • Blood pressure procedure refused
  • Blood test declined
  • Blood transfusion declined
  • Body height measurement declined
  • Body mass index measurement declined
  • Body weight measurement declined
  • Bone density scan declined
  • Breast cancer screening declined
  • Breast neoplasm screening status
  • Breast screening non-attender
  • Breastfeeding support declined
  • Bupropion refused
  • Calcium channel blocker declined
  • Cancer cervix screening - not attended
  • Cardiac rehabilitation declined
  • Cardiovascular disease risk assessment declined
  • Carotid artery doppler declined
  • Carvedilol therapy declined
  • Cervical cancer Papanicolaou smear screening declined
  • Chemical dependency consultation declined
  • Child 1 year examination not wanted
  • Child 21 month examination not wanted
  • Child 3 year exam not wanted
  • Child 39 month examination not wanted
  • Child 6 month examination not wanted
  • Child 6 week examination not wanted
  • Child 7 month examination not wanted
  • Child 8 week examination not wanted
  • Child examination at 1 year with explicit context
  • Child examination at 10 years with explicit context
  • Child examination at 15 years with explicit context
  • Child examination at 18 months with explicit context
  • Child examination at 2.5 years with explicit context
  • Child examination at 21 months with explicit context
  • Child examination at 3 years with explicit context
  • Child examination at 3.5 years with explicit context
  • Child examination at 39 months with explicit context
  • Child examination at 4.5 years with explicit context
  • Child examination at 6 months with explicit context
  • Child examination at 6 weeks with explicit context
  • Child examination at 7 months with explicit context
  • Child examination at 8 to 9 months with explicit context
  • Child examination at 8 weeks with explicit context
  • Child surveillance not wanted
  • Chlamydia screening declined
  • Cholesterol reduction program declined
  • Clinical trial declined
  • Clopidogrel declined
  • Colon cancer screening declined
  • Colonoscopy refused
  • Combined calcium and vitamin D3 preparation declined
  • Community resource finding
  • Congenital hypothyroidism screening declined
  • Consent declined for examination of cardiovascular system
  • Consent declined for examination of central nervous system
  • Consent declined for examination of gastrointestinal system
  • Consent declined for examination of genitourinary system
  • Consent declined for examination of musculoskeletal system
  • Consent declined for examination of respiratory system
  • Consent for operation refused
  • Coronary arteriography declined
  • Coronary heart disease monitoring refused
  • Counseling declined
  • Counseling not wanted
  • CT scan brain declined
  • Cystic fibrosis screening declined
  • Declined consent for treatment
  • Declined to perform inhaler technique
  • Depression screening declined
  • Diabetes screening declined
  • Diabetic foot examination declined
  • Diabetic retinopathy screening refused
  • Diagnostic procedure declined
  • Did not attend
  • Did not attend - reason given
  • Did not attend abdominal aortic aneurysm screening
  • Did not attend cardiac clinic
  • Did not attend cholesterol clinic
  • Did not attend community psychiatric nurse review
  • Did not attend dentist in last 12 - 18 months
  • Did not attend diabetic clinic
  • Did not attend dietetic clinic
  • Did not attend hospital appointment
  • Did not attend peripheral vascular disease clinic
  • Did not attend physiotherapy appointment
  • Did not attend podiatry clinic
  • Did not attend psychiatry clinic
  • Did not attend substance misuse clinic
  • Discussion about advance care planning declined
  • Diuretic declined
  • DNA - Did not attend mental health appointment
  • DNA - Did not attend outpatient appointment
  • Double test not wanted
  • Drug declined by patient
  • Drug declined by patient - reason unknown
  • Drug screening declined
  • DXA scan declined
  • Echocardiogram declined
  • Education about physical exercise refused
  • Environmental risk assessment declined
  • Exercise tolerance test refused
  • Failed encounter
  • Fall risk assessment declined
  • Follow-up encounter refused
  • Foot pulse check declined
  • GAD-7 scale declined
  • Geriatric monitoring refused
  • Geriatric screening declined
  • Glaucoma screening declined
  • History refused
  • History taking of sexual orientation declined
  • HIV screening declined
  • Home oxygen therapy declined
  • Hormone replacement therapy refused
  • Hypertension monitoring refused
  • Hypertension treatment refused
  • Inadequate consent
  • Insulin declined
  • Invitation to participate in research study declined
  • Left care setting having refused treatment
  • Lipid lowering therapy declined
  • Lipid screening declined
  • Long acting reversible contraception declined
  • Lung cancer screening declined
  • Magnetic resonance imaging scan declined
  • Mammogram declined
  • Maternal postnatal examination not attended
  • Maternal postnatal examination refused
  • Measurement of waist circumference declined
  • Medication dosage increase declined
  • Medication refused
  • Medication review declined
  • Medication therapy management recommendation refused by patient
  • Medium-chain acyl-coenzyme A dehydrogenase deficiency screening test declined
  • Mental health assessment declined
  • Monitoring for stress refused
  • Monitoring of hormone replacement therapy refused
  • Monitoring of smoking cessation therapy refused
  • Mother refuses to breastfeed
  • Multidisciplinary team falls assessment declined
  • Naloxone therapy refused
  • Nebivolol therapy refused
  • New patient screening declined
  • Nicotine replacement therapy refused
  • Nitrate declined
  • Nurse triage declined
  • Obesity monitoring refused
  • Osteoporosis monitoring refused
  • Osteoporosis risk assessment refused
  • Osteoporosis screening declined
  • Osteoporosis treatment declined
  • Over 75 years of age health check declined
  • Parent craft not wanted
  • Part III accommodation refused
  • Patient declines information
  • Patient declines smoking cessation information
  • Patient declines tobacco cessation information
  • Patient defaulted from follow-up
  • Patient non-compliant - refused service
  • Patient non-compliant with specific advice
  • Patient refused hematology test
  • Patient refused laboratory test
  • Patient refused transportation
  • Patient refuses community resource assistance
  • Patient refuses day hospital
  • Patient refuses hospital admission
  • Patient refuses to enroll in care management program
  • Patient refuses to release medical information
  • Patient refuses to take medication
  • Patient refuses to verify personal information
  • Persistent non-attender
  • Phenylketonuria screening declined
  • Phosphodiesterase 5 inhibitor declined
  • Poor attender
  • Postnatal care refused
  • Prescription of anticipatory care medication declined
  • Primary health care team falls assessment declined
  • Procedure discontinued by patient
  • Procedure refused
  • Procedure refused - uncooperative
  • Prostate cancer screening declined
  • Provision of chaperone refused
  • Provision of patient held diabetes record refused
  • Radiology refused
  • Raloxifene therapy declined
  • Reasons for treatment delay
  • Recommendation refused by patient
  • Recommendations refused
  • Referral declined by patient
  • Referral to cardiac rehabilitation program declined
  • Referral to cardiologist refused
  • Referral to chiropodist declined
  • Referral to colorectal surgeon declined by subject
  • Referral to dietician declined
  • Referral to erectile dysfunction clinic declined
  • Referral to gastroenterologist declined by subject
  • Referral to gynecologist declined by subject
  • Referral to heart failure exercise program declined
  • Referral to nephrologist refused
  • Referral to neurologist declined by patient
  • Referral to oncologist declined by subject
  • Referral to ophthalmologist declined by subject
  • Referral to psychiatrist declined by subject
  • Referral to psychology service declined
  • Referral to respiratory clinic declined
  • Referral to respiratory physician declined by subject
  • Referral to specialist alcohol treatment service declined by patient
  • Referral to specialist refused
  • Refusal by patient to provide information about ethnic group
  • Refusal by patient to provide information about religion
  • Refusal by patient to provide information about spoken language
  • Refusal of treatment by patient against dental advice
  • Refused procedure - after thought
  • Refused referral to minor ailments clinic
  • Refuses diabetes monitoring
  • Refuses meals on wheels
  • Registration for online access to local general practice service declined
  • Review of advance care plan declined
  • Risk assessment refused
  • Routine enquiry about domestic abuse declined
  • Rubella screening not wanted
  • Sampling of chorionic villus refused
  • Screening chest X-ray declined
  • Screening declined
  • Screening for Human papillomavirus declined
  • Screening for malignant neoplasm of cervix declined
  • Screening for malignant neoplasm of cervix not wanted
  • Screening invite -not attended
  • Screening not wanted
  • Selective estrogen receptor modulator declined
  • Shared care prescribing declined
  • Shared care prescribing of drugs for dementia declined
  • Sickle cell screening declined
  • Social Services help refused
  • Spirometry test declined
  • Statin declined
  • Strontium ranelate declined
  • Support for caregiver during weaning declined
  • Teriparatide therapy declined
  • Thrombolytic therapy refused
  • Treatment delay - patient choice
  • Triple test not wanted
  • Tuberculosis screening declined
  • Type 2 diabetes mellitus risk assessment declined
  • Urine dipstick test declined
  • Vaginal birth after previous cesarean section refused
  • Vascular disease risk assessment declined
  • Vitamin K prophylaxis declined
  • Warfarin declined
  • Weight management advice declined
  • Well man health check refused
  • Well woman health check refused

Convert Z53.20 to ICD-9

  • V64.06 - No vaccination-pt refuse (Approximate Flag)
  • V64.2 - No proc/patient decision (Approximate Flag)

Code Classification

  • Factors influencing health status and contact with health services (Z00–Z99)
    • Encounters for other specific health care (Z40-Z53)
      • Persons encntr hlth serv for spec proc & trtmt, not crd out (Z53)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020