# Opinions Please



## jperkins (Jul 25, 2017)

Hello.  I am wondering how other coders deal with resolved conditions.  The patient came in for follow up of dermatitis. No findings on exam. Plan states diagnosis as dermatitis (L30.8) resolved.  Patient will return prn.  I have also seen new patient visits where the patient came in with a chief complaint of a condition but in the HPI and exam there are no findings and the condition complained about has cleared up but in the diagnosis the physician has put the condition the patient came in for noting it is resolved and to return to clinic if the condition recurs.  Thank you for offering your opinions/advice.


----------



## HangarPilot (Jul 25, 2017)

In pediatrics we see a good number of follow-ups to confirm treatment was successful. For example, ear infections - it's not readily apparent to the parent if the ear infection is gone or not and repeated ear infections can cause hearing damage - we bring them back in two weeks to confirm the antibiotic was effective. If was not effective, it is again coded as an ear infection and the patient is placed on a bigger, badder antibiotic (or referred to ENT or both).

In cases where it is resolved, we code:
Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z86.69 - Personal history of other diseases of the nervous system and sense organs (history of otitis media)

In your example, you could code Z09 followed by Z87.2- Personal history of diseases of the skin and subcutaneous tissue.


----------



## jperkins (Jul 26, 2017)

Thank you for your response. I appreciate your input.


----------



## thomas7331 (Jul 27, 2017)

If the patient is following up for treatment of a condition and the physician has not yet made the determination that the condition is resolved until that visit, most coders I've worked with would still code the diagnosis of the condition since that most accurately reflects the reason for the visit - the patient is still there for treatment of that problem, even though the physician then makes the determination that it is resolved.  I think the Z codes are more accurately used, per the guidelines, for surveillance after treatment has been completed, in other words for any additional visits after the provider has documented the problem as resoled, for example, a visit to evaluate for possible recurrence or late effects of the disease or treatment.


----------



## jperkins (Jul 27, 2017)

Thank you. I appreciate the information.


----------

