ICD-10-CM Code Z53.9

Procedure and treatment not carried out, unspecified reason

Version 2020 Billable Code Unacceptable Principal Diagnosis

Valid for Submission

Z53.9 is a billable code used to specify a medical diagnosis of procedure and treatment not carried out, unspecified reason. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Z53.9 might also be used to specify conditions or terms like 360 degree sweep of cervix not performed, allergy testing not done, antenatal blood group screening not done, antenatal sickle screening not done, antenatal syphilis screening not done, asthma action plan not done, etc

The code Z53.9 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.

Short Description:Procedure and treatment not carried out, unspecified reason
Long Description:Procedure and treatment not carried out, unspecified reason

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 Z53.9 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.


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

  • 360 degree sweep of cervix not performed
  • Allergy testing not done
  • Antenatal blood group screening not done
  • Antenatal sickle screening not done
  • Antenatal syphilis screening not done
  • Asthma action plan not done
  • Auditory/vestibular test not done
  • Autopsy waived
  • Block dissection of cervical lymph nodes not done
  • Blood pressure not taken
  • Body mass index follow-up planning not done
  • Body mass index measurement not done
  • Bone density screening not done
  • Bowel preparation not done
  • Breast cancer screening not done
  • Canceled operative procedure
  • Cardiac function test not done
  • Cardiopulmonary resuscitation not attempted
  • Cardiovascular system not examined
  • Cell phenotyping not performed
  • Cervical cancer screening not done
  • Chemotherapy not done
  • Child examination at 10 days with explicit context
  • Child examination at birth with explicit context
  • Child not examined at 10 days
  • Child not examined at birth
  • Colorectal cancer screening not done
  • Counseling about firearm safety not done
  • Counseling about opioid safety not done
  • CSF chemistry - not tested
  • CSF: not examined
  • Cytogenetic study not performed
  • Delay of chemotherapy
  • Delay of drug therapy
  • Delayed hypersensitivity skin test for histoplasmin not done
  • Depression screening not done
  • Determination of pattern of resistance to antiviral agent not done
  • Diabetes mellitus screening not done
  • Diabetic education not done
  • Diabetic foot examination not done
  • Diabetic retinal eye exam not done
  • Did not attend - no reason
  • Domestic abuse not discussed
  • Drug discontinued - reason unknown
  • Drugs not taken/completed
  • ECG not done
  • Endoscopy not carried out
  • ENT examination not performed
  • Exercise tolerance test not done
  • Failed encounter - message left on answer machine
  • Failed encounter - message left with household member
  • Failed encounter - message left with work place
  • Failed encounter - no answer when rang back
  • Failed encounter - phone number unobtainable
  • Failed encounter - practitioner access denied
  • Fall risk assessment not done
  • Feces not examined
  • Finding of serum tumor marker level
  • General examination not done
  • GIT not examined
  • GU system not examined
  • Heart failure education not done
  • Hematology test request - not done
  • Hemoglobin A1C test not done
  • Hemoglobin not estimated
  • Human immunodeficiency virus screening not done
  • Hyperlipidemia screening test not done
  • Hypersensitivity skin test not done
  • Hypertension monitoring check not done
  • Hypertension monitoring status
  • Immunophenotypic analysis not done
  • Kidney biopsy not done
  • Kveim test not done
  • Laboratory test requested - not done
  • Lung function testing not done
  • Lung volume test not done
  • Mantoux test not done
  • Medication education not done
  • Medication not administered
  • Metabolic function not tested
  • Multidisciplinary team falls assessment defaulted
  • Musculoskeletal test not done
  • Nervous system not examined
  • Neurological diagnostic procedure - not done
  • No antenatal care
  • No anti-cancer treatment - advanced stage cancer
  • No history of procedure
  • No stain applied
  • Non-surgical biopsy not done
  • O/E - CNS not examined
  • O/E - extremities not examined
  • O/E - skin not examined
  • O/E - temperature not taken
  • On examination - sensory system not examined
  • Operation abandoned
  • Operation abandoned before onset
  • Operation not completed
  • Operative procedure canceled after time of induction of anesthesia
  • Operative procedure canceled before anesthesia start time
  • Operative procedure canceled before time of induction of anesthesia
  • Orthopedic exam. not done
  • Osteoporosis risk assessment defaulted
  • Patient assessment for procedure not done
  • Patient died before anti-cancer treatment
  • Patient not examined
  • Peak expiratory flow not done
  • Postnatal depression not discussed
  • Previously initiated dental therapy not completed
  • Primary health care team falls assessment defaulted
  • Procedure discontinued by doctor
  • Procedure discontinued by healthcare professional
  • Procedure not done
  • Procedure not ordered
  • Radiation therapy not done
  • Radiographic imaging procedure not carried out
  • Reason for no specific anti-cancer treatment
  • Reason for no specific anti-cancer treatment
  • Reasons for treatment
  • Reasons for treatment
  • Respiratory flow rate not measured
  • Respiratory system not examined
  • Retinae not examined
  • Serum metabolic panel not done
  • Serum tumor marker stage SX
  • Shuttle walking test not done
  • Special cardiovascular system test not done
  • Special ENT procedure not done
  • Special female test not done
  • Special GIT test not done
  • Special male test not done
  • Special urinary test not done
  • Spirometry not done
  • Susceptibility skin test not done
  • Tobacco cessation education not done
  • Tobacco usage screening not done
  • Urine bacteria test not done
  • Urine blood test not done
  • Urine glucose test not done
  • Urine ketone test not done
  • Urine leukocyte test not done
  • Urine not examined
  • Urine pH test not done
  • Urine protein test not done
  • Urine urobilinogen not tested
  • Visual testing not done

Convert Z53.9 to ICD-9

  • V64.3 - No proc for reasons NEC (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