ICD Code Z91.09

ICD code Z91.09 is a code used to indicate a patient's noncompliance with medical treatment and regimen for reasons not elsewhere classified.

1. Documented history of nonadherence to medical treatment or regimen

2. Patient’s noncompliance is not due to mental disorder

3. Nonadherence is not specified as intentional or unintentional

4. Nonadherence is not due to financial hardship, misunderstanding, or other specified reasons

5. Evidence of repeated missed appointments, failure to take prescribed medications, or not following recommended lifestyle modifications

6. Provider has counseled the patient regarding the importance of adherence

7. Nonadherence is clinically relevant to the patient’s current care or health outcomes

Relevant CPT codes that may be used to treat ICD code Z91.09 include:

- 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention)

- 99406–99407 (Smoking and tobacco use cessation counseling visit)

- 99408–99409 (Alcohol and/or substance abuse structured screening and brief intervention services)

- 96160 (Administration of patient-focused health risk assessment instrument)

- 96161 (Administration of caregiver-focused health risk assessment instrument)

- 99201–99215 (Evaluation and management services, new or established patient, office or other outpatient visit)

- 99381–99397 (Preventive medicine services, new or established patient)

These CPT codes are commonly associated with ICD code Z91.09.

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