20 Other Conditions That May Be a Focus of Clinical Attention V-codes and z-codes V-codes and Z-codes are conditions that may be the focus of clinical attention but are not considered mental disorders. They correspond to International Classification of Diseases, Ninth Revision, Clinical Modification ICD-9-CM (V-codes) and International Classification of Diseases, Tenth Revision, Clinical Modification ICD-10-CM (Z-codes that become effective in 2015. In most instances, third-party payers do not cover charges for delivering services to an individual if the diagnosis is solely a V- or Z-code alone. If the V- or Z-code is not the primary diagnosis then it should be documented following the primary diagnosis. In addition, when writing the psychosocial assessment any psychosocial and cultural factors that might impact the client's diagnosis should be documented. The psychosocial stressors reflected in these diagnoses are widespread across all classes and cultures and have been shown to impact all aspects of an individual's life from the physical and psychological to the financial. Furthermore, these conditions have been shown to significantly impact the diagnosis and outcome for a multitude of mental and medical disorders. V- and Z-codes are grouped into numerous categories including: relational problems, problems related to abuse/neglect, educational and occupational problems, housing and economic problems, problems related to the social environment, problems related to the legal system, other counseling services, other psychosocial, personal and environmental problems, and problems of personal history (APA, 2013).    Broadly speaking, the category “Relational Problems” describes interactional problems between family members (e.g., parent/caregiver-child) or partners that result in significant impairment of family functioning or development of symptoms in the distressed individual, spouses, siblings, or other family members. Relational problems are broken down into two categories, Problems Related to Family Upbringing and Other Problems Related to Primary Support Group. For example, in the first category a Parent-Child Relational Problem involves interactional problems between one or both parents and a child that lead to dysfunction in behavioral (e.g., inadequate protection, overprotection), cognitive (e.g., antagonism toward or blaming of the other) or affective (e.g., feeling sad and angry) realms. Here, the critical factor is the quality of the parent-child relationship or when the dysfunction in this relationship is impacting the course and outcome of a psychological or medical condition. Other examples include Sibling Relational Problem, Upbringing Away from Parents, and Child Affected by Parental Relationship Distress. Similarly, family relationships and interactional patterns leading to problems related to primary support group include Partner Relational Problem, Disruption of Family by Separation/Divorce, High Expressed Emotion Level with ...

1. 20 Other Conditions That May Be a Focus of Clinical Attention
V-codes and z-codes
V-codes and Z-codes are conditions that may be the focus of
clinical attention but are not considered mental disorders. They
correspond to International Classification of Diseases, Ninth
Revision, Clinical Modification ICD-9-CM (V-codes) and
International Classification of Diseases, Tenth Revision,
Clinical Modification ICD-10-CM (Z-codes that become
effective in 2015. In most instances, third-party payers do not
cover charges for delivering services to an individual if the
diagnosis is solely a V- or Z-code alone. If the V- or Z-code is
not the primary diagnosis then it should be documented
following the primary diagnosis. In addition, when writing the
psychosocial assessment any psychosocial and cultural factors
that might impact the client's diagnosis should be documented.
The psychosocial stressors reflected in these diagnoses are
widespread across all classes and cultures and have been shown
to impact all aspects of an individual's life from the physical
and psychological to the financial. Furthermore, these
conditions have been shown to significantly impact the
diagnosis and outcome for a multitude of mental and medical
disorders. V- and Z-codes are grouped into numerous categories
including: relational problems, problems related to
abuse/neglect, educational and occupational problems, housing
and economic problems, problems related to the social
environment, problems related to the legal system, other
counseling services, other psychosocial, personal and
environmental problems, and problems of personal history
(APA, 2013).
Broadly speaking, the category “Relational Problems”
describes interactional problems between family members (e.g.,
parent/caregiver-child) or partners that result in significant
impairment of family functioning or development of symptoms
in the distressed individual, spouses, siblings, or other family

2. members. Relational problems are broken down into two
categories, Problems Related to Family Upbringing and Other
Problems Related to Primary Support Group. For example, in
the first category a Parent-Child Relational Problem involves
interactional problems between one or both parents and a child
that lead to dysfunction in behavioral (e.g., inadequate
protection, overprotection), cognitive (e.g., antagonism toward
or blaming of the other) or affective (e.g., feeling sad and
angry) realms. Here, the critical factor is the quality of the
parent-child relationship or when the dysfunction in this
relationship is impacting the course and outcome of a
psychological or medical condition. Other examples include
Sibling Relational Problem, Upbringing Away from Parents, and
Child Affected by Parental Relationship Distress. Similarly,
family relationships and interactional patterns leading to
problems related to primary support group include Partner
Relational Problem, Disruption of Family by
Separation/Divorce, High Expressed Emotion Level within
Family and Uncomplicated Bereavement. For example,
Disruption of Family by Separation or Divorce should be used
when intimate partners/spouses are living separately due to
relationship problems or pending divorce (APA, 2013).
The V-codes subsumed under the broad category of “Problems
Related to Abuse or Neglect” are broken down into two
categories, one for children and the other for adults. The Child
Neglect category includes the following: Physical Abuse of
Child; Sexual Abuse of Child; Neglect of Child, and Child
Psychological Abuse. Under Adult Abuse or Neglect the
categories include Spouse/Partner Physical Abuse;
Spouse/Partner Sexual Abuse; Spouse/Partner Neglect; Spouse/
Partner Psychological Abuse; and Abuse of Adult (non-
spouse/partner), which includes physical, sexual, and
psychological abuse of an adult. The V-codes are used when the
focus of attention is on the perpetrator of child or adult abuse
and/or neglect and are not due to a mental disorder. If the focus
of the attention is on the victim/survivor of the abuse, the codes

3. 999.5 for children with the 5th digit tied to the type of abuse
(e.g., physical 4, sexual 3, psychological 1) and 995.8 for adults
with the 5th digit tied to the type of abuse (e.g., physical 1,
sexual 3, psychological 2) are used. Also, whether this is an
initial or subsequent encounter with the client, and whether the
abuse is confirmed or suspected is coded in the ICD-10-CM in T
codes in the 7th digit. A past history of abuse/ neglect in the
client is coded separately (APA, 2013).
The remaining broad categories of V-codes include
Educational (i.e., problems related to literacy) and Occupational
Problems (e.g., Problems related to current Military Deployment
status); Housing Problems, Economic Problems (e.g., extreme
poverty); Other Problems Related to the Social Environment
(e.g., Acculturation Problem and Phase of Life Problem);
Problems with the Legal System (e.g., imprisonment or
incarceration); Other Counseling and Medical Advice (e.g., sex
counseling); Problems Related to Other Psychosocial, Personal,
and Environmental Circumstances (e.g., Religious or Spiritual
Problem, Victim of Terrorism, Exposure to War); Other
Circumstances of Personal History (e.g., Adult or Child
Antisocial Behavior); Problems Related to Medical Access and
Other Health Care; and Non-adherence to Medical Treatment
(e.g., Malingering, Borderline Intellectual Functioning) (APA,
2013).
Assessment
The psychosocial assessment that is most useful for evaluation
of V-codes and other psychosocial and environmental stressors
can be found at the end of Chapter 1. As practitioners a
biopsychosocial and spiritual framework should be the guiding
factor when making diagnosis and treatment decisions, utilizing
a strengths-based and person-centered perspective.
Cultural Considerations
Stressors that may affect people adversely differ among ethnic
groups and cultures. For example, an event that might be
perceived and labeled as stressful to an Anglo-American
individual may not be considered stressful to an individual

4. living in South America, Japan, China, or the Congo. In
addition, how individuals cope with stress is largely defined by
the culture and society in which they live. For example, in the
United States, families and individuals consider divorce to be a
stressful life transition that may require assistance from
professionals. In other cultures, leaving a partner may involve
only a verbal dissolution of the relationship and change of
residence.
What constitutes a psychosocial stressor in the United States
and Western European countries may not be considered stressful
or distressful in other cultures. It is important to be sensitive to
cultural differences in regard to psychosocial well-being and
not label something as a stressor when it may not be considered
so in other cultures. By the same token, practitioners need to be
cognizant of their own cultural biases and stereotypical ideas.
Either minimizing or maximizing symptoms because of a
person's cultural background alone could result in an
inappropriate psychosocial assessment.
A large body of literature exists that examines the causes of
stress, its impact on individuals' lives, coping strategies, and
interventions designed to reduce the negative effects of stress
on individuals' mental health. In recent years, researchers have
turned their attention to the relationship between sociocultural
factors and identifiable stressors experienced by people of
different ethnic and social backgrounds in the United States and
other countries worldwide. The relationship between stress and
socioeconomic status has been examined in relation to behavior
disorders in children (Fergusson, Boden, & Horwood, 2013). A
comparison of social stressors in lesbian, gay, and bisexual
populations and heterosexuals has been studied (Meyer, 2003).
The stressors related to being a gay, lesbian, and bisexual youth
have been shown to increase the risk and incidence of suicidal
behavior (Hatzenbuehler, 2011). The stress and strain related to
being a minority group member in a country (termed
“acculturative stress”) are delineated in studies of Latino adults
(Torres, Driscoll, & Voell, 2012), elderly Asian immigrants

5. (Mui & Kang, 2006), and in Hispanic immigrant women in
marital therapy (Negy, Hammons, Reig-Ferrer, & Carper, 2010)
A widely researched model of stress and coping developed by
Lazarus and Folkman (1984) suggests that stressors may impact
individuals in a variety of ways depending on how they
cognitively process the stressful event. First, the individual
makes a “primary appraisal” of the stressful event (What has
just happened? Am I in danger? How has this stressor affected
me?). Second, the individual makes a “secondary appraisal” of
the event (What can I do about this stressor? How will I cope
with this event?). Third, the individual uses available coping
skills (e.g., avoidance, problem-solving, and emotion-focused
skills) to attempt to ameliorate the effects of the stressor.
Finally, the individual adapts to the stressor, which results in
positive, negative, or neutral consequences.
Slavin, Rainer, McCreary, and Gowda (1991) as well as Kuo
(2011) proposed the addition of a multicultural component to
Lazarus and Folkman's model. Since the perception of stress is a
culturally bound issue, it is important to take into account the
cultural experiences of the individual in assessing the impact of
stress on the individual. The authors suggest that, in addition to
assessing the seriousness of the stressor, the practitioner should
be aware of the stressor as related to minority status, potential
discrimination, disadvantaged socioeconomic status, and
specific cultural customs of the individual experiencing the
stress-related event. Second, in regard to the primary appraisal
of the event, the counselor should take into consideration the
person's or family's cultural definition of the event and the
person's or family's cultural frame of reference for
understanding the event. Third, from a multicultural viewpoint,
assessment of secondary appraisal options (coping mechanisms)
should include the individual's culturally bound behavioral
options, role definitions, ethnic identity, and definition of
family, group, and social network. Attempts to cope with the
stressful event should include consideration of the individual's
cultural rituals, cultural and mainstream sanctions against

6. certain coping strategies, and biculturation (the incorporation of
both minority and mainstream coping skills). Finally, the
outcomes of coping strategies should be assessed according to
the person's cultural framework and norms for the cultural
group. Each of these steps in the process can be added to the
basic model proposed by Lazarus and Folkman (1984) when
considering the multicultural factors related to stressful events
and situations.
Social Support Systems
The impact of V- and Z- Codes on an individual's social support
system can vary dramatically. A primary consideration in
assessing the impact is the degree to which one or more
members are also being affected by the situation. A person who
is not directly affected may be more willing to extend support.
At the same time, this less involved individual may find it
harder to really empathize with the client's situation. Clearly,
when the issues are relational, the possibility of continued (and
even escalating) conflict can result in other members of the
social support systems withdrawing or aligning themselves with
one of the parties.
Although it was common in the 1980s for insurance
companies to reimburse practitioners for treatment of V-codes,
the managed-care shift in the new millennium marks the need
for creative interventions and solutions for these categories of
psychosocial functioning. Support groups can provide critical
resources in situations where more formal treatment is not
available (or desired). Whether sponsored independently or as
part of church-related or nonprofit organizations, most of the
resources are organized around a particular concern. For
example, support groups dealing with individuals with such
difficulties as divorce recovery, relocation, empty-nest
syndrome, school-based social networks, chronic illness
recovery/caregiving groups, employee assistance programs,
relationship/sexual support groups, single persons' support
networks, parent education programs, and anger-management
group interventions are widely available. There is a unique

7. value in sharing experiences related to stressful situations with
mutual-aid support groups. Such safe and confidential
environments reduce shame, stigma, guilt, burden, and fear
among members. Often, a combination of a few individual
therapy sessions along with ongoing support groups can lead to
satisfactory outcomes for the individual with a V-code
diagnosis.
Other community resources that might prove useful in certain
situations may include recreation or after-school programs for
youth, psychoeducational programs or workshops provided by
nonprofit agencies, holistic approaches to health (e.g., yoga,
meditation groups, or exercise programs), advocacy and service
opportunities, meals-on-wheels, mentoring programs, and senior
centers.
Case 20.1
Since V-codes are commonly associated with most disorders,
cases throughout this text should be considered for their V-code
designation. For example, the majority of cases in this
workbook contain V-codes that need to be identified. As stated
earlier, a thorough assessment as outlined in Chapter 1 includes
a focus on the psychosocial and cultural stressors in the person's
environment. The practitioner begins the assessment process by
talking with the client about any potential psychosocial issues
Case 20.1 that may be creating barriers in the person's daily and
overall functioning. Only after gathering a comprehensive
picture of the client's functioning in the biopsychosocial and
spiritual realms will the practitioner be able to make an
appropriate diagnosis. Therefore, practice in uncovering the
psychosocial issues confronting clients is an integral part of the
conceptualization for each of the cases in this text. Please
review the cases in Chapter 21 for more examples of assessing
V- and Z-codes.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
Author.

8. Fergusson, D. M., Boden, J. M., & Horwood, L. (2013).
Childhood self-control and adult outcomes: Results from a 30-
year longitudinal study. Journal of the American Academy of
Child & Adolescent Psychiatry, 52(7), 709–717.
doi:10.1016/j.jaac.2013.04.008
Hatzenbuehler, M. L. (2011). The social environment and
suicide attempts in lesbian, gay and bisexual youth. Pediatrics,
127, 896–903.
Kuo, B. C. H. (2011). Culture’s consequences on coping:
Theories, evidences, and dimensionalities. Journal of Cross-
Cultural Psychology, 42(6), 1084–1100.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and
coping. New York: Springer.
Meyer, I. H. (2003). Prejudice, social stress, and mental health
in lesbian, gay, and bisexual populations: Conceptual issues and
research evidence. Psychological Bulletin, 129(5), 674–697.
Mui, A. C., & Kang, S. Y. (2006). Acculturation stress and
depression among Asian immigrant elders. Social Work,
51, 243–255.
Negy, C., Hammons, M. E., Reig-Ferrer, A., & Carper, T. M.
(2010). The importance of addressing acculturative stress in
marital therapy with Hispanic immigrant women. International
Journal of Clinical Health and Psychology, 10(1), 5–21.
Retrieved March 14, 2014,
from http://www.redalyc.org/pdf/337/33712017001.pdf
Slavin, L. A., Rainer, K. L., McCreary, M. L., & Gowda, K. K.
(1991). Toward a multicultural model of the stress
process. Journal of Counseling and Development, 70, 156–163.
Torres, L., Driscoll, M. S., & Voell, M. (2012). Discrimination,
acculturation, acculturative stress, and Latino psychological
distress: A moderated mediational model. Cultural Diversity &
Ethnic Minority Psychology, 18(1), 17–25. Retrieved March 14,
2014,
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340887/

9. Week 6
Respond to the following question in a minimum of 175 words
each question, post must be substantive responses:
Explain v-codes and z-codes and how they inform and guide
treatment. How are they different from the ICD-10 F-codes?
Respond to classmates in a minimum of 175 words each person,
post must be substantive responses:
D.B.
V-codes, described in the ICD-9-CM are "designed for
occasions when circumstances other than a disease or injury
result in an encounter or are recorded by providers as problems
or factors that influence care". Under ICD-10-CM, these
services are reported under Z-codes. Z-codes may be used as
either a first-listed (principal diagnosis code in the inpatient
setting) or secondary code, depending on the circumstances of
the encounter. Certain Z-codes may only be used as first-listed
or principal diagnosis. Z-codes are used when a circumstance or
problem that influences the person's health status is present but
is not in itself a current illness or injury. These codes can guide
treatment by providing additional information about the
patient's history. For example, a Z code for heart transplant
status would guide the care of the patient even though that is
not the reason for the current encounter.
ICD-10 F-codes are diagnosis codes for anxiety, dissociative,
stress-related, somatoform and other nonpsychotic mental
disorders. These are diagnosis codes for mental and behavioral
health. Z-codes represent reasons for encounters, while F-codes
represent a diagnosis.
H.G.
V and z codes may be focused on in treatment but are not
considered to be a mental health disorder. V and z codes are
considered a classification of things that may be focused on by
a counselor. Some insurances and other companies will not

10. accept v and z codes as a diagnosis. V and z codes may be
something discussed in the section of other things that may be
focused on. For example, legal problems or encounter with the
legal system, or relationship problems. Another thing that may
fall under the z and v codes is neglect and abuse. There are
other things that individuals may be experiencing problems with
but there is no diagnosis. It is important that there is awareness
of other issues or problems that may come up when assisting an
individual. The ICD-10-F codes are more related to the DSM 5
and involve more recognizable problems. When assisting an
individual, it is important to develop a proper diagnosis and one
may attach the v and z codes. Individuals may experience a
variety of problems so it is important to be aware of different
areas individuals may be experiencing problems in.
Reference:
Pomeroy, E. (2014). The Clinical Assessment Workbook:
Balencing Strengths and Differential Diagnosis. (2nd ed.).
Boston, MA: Cengage Learning.