Resolved Z09 Hospital Follow Up

[AlexandriaB_65125]

I’m in a dilemma with this Z09 code, I understand they are used to explain continuing surveillance following completed treatment of a disease, condition or injury. They imply that the condition has been fully treated and no longer exists. But what if the provider states hospitalization follow up is improved? I know a follow up history code is what is used after z09, but the provider has J11.1 “improved”, am I ok to use Z09 with J11.1 together? I see some instances where provider has pt doing well and continuing with meds they were discharged with as well.

 

[Lori]

Z09
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Applicable To

• Medical surveillance following completed treatment

Use Additional

• code to identify any applicable history of disease code (Z86.-, Z87.-)

Type 1 Excludes

• aftercare following medical care (Z43-Z49, Z51)
• surveillance of contraception (Z30.4-)
• surveillance of prosthetic and other medical devices (Z44 -Z46)

Approximate Synonyms

• Follow up after surgical procedure
• Follow up exam
• Follow up exam after completing treatment
• Follow up exam after completion of non-cancer treatment done
• Follow up exam after completion of treatment done
• Isoniazid (inh) treatment completed after positive ppd (tb skin test)
• Isoniazid treatment after positive ppd done
• Surgery follow-up done

7) Aftercare
Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The aftercare codes are generally first listed to explain the specific reason for the encounter. Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae.

Aftercare codes are found in categories Z42-Z49 and Z51.

Reporting Encounters for Aftercare

Reporting rules for aftercare are as follows:

• The aftercare Z-code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule include:
  • Codes for encounters for antineoplastic radiation, chemotherapy and immunotherapy (Z51.0, Z51.1-) are assigned if the sole reason for the encounter is antineoplastic therapy – even if the patient still has the neoplastic disease.
  • Aftercare for injuries is not reported with Z-codes. Assign the Z-code with the appropriate seventh character for subsequent care.
• The aftercare codes are generally the first listed diagnosis.
• Aftercare codes should be used in conjunction with other aftercare codes, diagnosis codes and/or other categories of Z-codes to provide better detail on the specifics of the aftercare encounter/visit, unless otherwise directed by the classification.
• Certain aftercare Z-codes require a secondary diagnosis code to describe the resolving condition or sequela. For other aftercare codes, the condition is included in the code description and a secondary diagnosis is not required.

ICD-10-CM Coding for Aftercare​

The codes for factors influencing health and contact with health services represent reasons for encounters. In ICD-10-CM, these codes are located in

www.icd10monitor.com



8) Follow-up
The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes, or injury codes with a 7th character for subsequent encounter, that explain ongoing care of a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.

https://californiahia.org/sites/cal...cles/2016-may-june-aftercare-vs-follow-up.pdf

Resource - Z Codes

The Importance of Z Codes Z codes, found in Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) of the ICD-10-CM code book, may be used in any healthcare setting. The ICD-10-CM Guidelines for Coding and Reporting instruct us to code for all coexisting...

www.cco.community