Z30.430 - Encounter for insertion of intrauterine contraceptive device

Clinical Definition

Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis that primarily affects the lungs, though it can affect other parts of the body. Active TB disease requires clear documentation of bacteriological or histological confirmation and the specific site of infection.

Documentation Requirements

• Confirmation Method:

  • Bacteriological confirmation required (culture results)

  • Histological confirmation acceptable

  • Documentation of diagnostic testing method

• Site Specificity:

  • Primary site of infection

  • Any secondary sites if disseminated

• Disease Status:

  • Active vs. latent

  • Initial episode vs. relapse

• Treatment Status:

  • Current medications

  • Response to therapy

  • Compliance with treatment regimen

Common Synonyms

• TB

• Consumption (historical)

• Koch's disease

• White plague

• Phthisis

Coding Conflicts

Excludes1:

• Congenital tuberculosis

• Pneumoconiosis associated with tuberculosis

• HIV disease resulting in tuberculosis

• Sequelae of tuberculosis

Scribing.io Automation

The AI scribe automatically detects:

• Keywords indicating TB diagnosis ("acid-fast bacilli," "MTB positive")

• Laboratory confirmation terminology

• Treatment regimen details

• Anatomical location specifics

• Monitors for exclusionary conditions

• Flags missing documentation elements required for proper coding

The system prompts for additional documentation if key elements are missing from the note.