# Post op icd-10 after global days



## calderm (Apr 12, 2017)

Hello!  Which ICD-10 Code(s) are used as a diagnosis for a patient seen for a follow-up from an excision of a lesion after the global period?


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## mitchellde (Apr 12, 2017)

You would use the path result if it is a neoplasm, otherwise you use Z09.


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## ellzeycoding (Apr 12, 2017)

I disagree. I wouldn't use the path result code for the follow-up E/M.  The inclusion of the ICD-10 code from path, infers that the condition still exists. If the neoplasm has been removed, it no longer exists!

From the ICD-10 manual...

_""J. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. *Do not code conditions that were previously treated and no longer exist.* However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment._"



Use the follow-up codes and personal history codes instead...

From the ICD-10 manual...

_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.

A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code.

The follow-up Z code categories:

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z39 Encounter for maternal postpartum care and examination_


Also, ICD-10 states when using the Z08/Z09 codes...

_Use Additional Code

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


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## mitchellde (Apr 13, 2017)

If the path result was a malignancy then the condition does still exist.  That is why I stated to code from path if it was a malignant neoplasms and use the followup for everything else.  Just because the lesion was removed does not indicate in all instances that the entire neoplasm was removed.  There is usually more treatment that will be performed as a result.


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## ellzeycoding (Apr 13, 2017)

Strongly disagree.  Lesions are excised all the time with pathology showing clean margins and therefor any followup for that lesion is for a lesion that no longer exists.  

Basal cell carcinoma, squamous cell carcinoma, melanoma in-situ, etc.  It can be cut out and REMOVED.  Therefor it no longer exists.

This is the reason for the personal history and Z codes.

Malignant lesions are not always metastasized conditions. 

Most are local and contained to a specific lesion. They can be totally removed.


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## mitchellde (Apr 13, 2017)

Having worked in Cancer Research, I disagree.  But that is what makes the world go around


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## ellzeycoding (Apr 13, 2017)

I understand your right to disagree.  However, I've been working in Dermatology for 25 years as a coding consultant and educator and have helped bill for hundreds of millions of dollars in dermatology insurance claims during that time.

Part 2 of my respopnse.

In the fairly uncommon event that exicsion was incomplete (dirty margins) and the patient has to come back for a re-excision, this is typically done within a postop period.  Most of the exicsion codes have 10 days... the repairs codes typically associated have 90 postop days.  So the global period is often quite long.

If a re-excision is needed WITHIN the postop period you code the re-exicision with modifier 58 as a staged procedure. and the same diagnosis (because it still exists at this point in time).

If outside the postop period, you code as just another excision with the same diagnosis because it still exists at this point in time).

In both instances, you most likely will not even have an E/M visit to bill as the E/M would be _included _in the minor surgical procedure (excision or re-excision) which have 10 days.  An E/M would only be billed for a *separate and identifiable* visit and wouldn't have the same diagnosis code anyways.

Mitchellede, you are over-thinking the question.  Please re-read the original posters question.  You are inserting many supppositions into the question that have nothing to do with the simple question that was posted.

And again, per ICD-10 instructions, you do not code an ICD-10 code for a condition that has been treated and no-longer exists.  Both benign *and *malignant neoplasms are removed all the time so that they no longer exist.


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## ellzeycoding (Apr 13, 2017)

Here are the Official 2017 ICD-10 Guidelines.

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf

Page 29, Section 2, d.


"*d. Primary malignancy previously excised*

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code."


I understand your cancer research background, but there is a HUGE difference between metastatic cancer and and cancers involving organs or organ systems requiring treatment modalities such as chemotherapy or radiation therapy  vs. skin neoplams that are most often contained to a specific area and can be excised per the original question.


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## mhstrauss (Apr 13, 2017)

Per the current ICD10CM guidelines, which category is used will depend on whether or not there is ongoing treatment:

m. Current malignancy versus personal history of malignancy
When a primary malignancy has been excised but further treatment,
such as an additional surgery for the malignancy, radiation therapy or
chemotherapy is directed to that site, the primary malignancy code
should be used until treatment is completed.
When a primary malignancy has been previously excised or eradicated
from its site, there is no further treatment (of the malignancy) directed
to that site, and there is no evidence of any existing primary
malignancy, a code from category Z85, Personal history of malignant
neoplasm, should be used to indicate the former site of the malignancy.
See Section I.C.21. Factors inf


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## mitchellde (Apr 13, 2017)

Ok lets take a breath.  I totally understand the guidelines.  However If you understand how the provider or at least the providers I work with will document.  If the pathology showed a malignant lesion even if the margins are clear, the follow up visit is not a follow up like they are if it is benign.  There is further examination to assure that there is no other abnormality, there is discussion with the patient regarding the malignant response and the possibility that there may be residual malignant cells, the need for frequent follow up and etc.  clear margins does always indicate cancer free status.  Therefor the malignant diagnosis is still being investigated, ie still treated.   It will be a higher intensity visit than if it was a completely benign or in situ response.  I continue to disagree.
I get what you are saying, but go by the documentation befor you decide to use a follow up code for a malignant pathology.  It has never fit do this by the documentation I use.


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## ellzeycoding (Apr 13, 2017)

I'm so sorry, but coding an ICD-10 code of malignant neoplasm (after removal) would be totally incorrect when it has been removed and no longer exists.

Show me the ICD-10 guidelines where it says this is acceptable after excision of malignant neoplasms when it has been excised and no longer exists to still code an E/M encounter with that previous condition.  The citations above show otherwise.  It's very clear.

In your case you're talking about any *E/M* that may be performed for a follow-up visit or semi-annual exam.  The additional work (i.e., potential for another comprehensive or detailed exam) is reflected in the final E/M code billed (based on the key components).  The level of E/M code billed is based on what's documented, not the ICD-10 code.

This happens all the time in dermatology.  A patient has a bunch of basal cells, a squamous cell, dysplastic neoplasm, etc.  These are removed.  The dermatologist wants the patient to come back in at 6 months for a checkup to make sure there are no new lesions appearing.   The dermatologist will do more work (more extensive exam usually), and sometimes end up with an higher level E/M visit.

The ICD-10 for this visit (if nothing new is found) is a *"personal history of XXXXX"*, which is the code that explains the necessity for the visit.   However, if any NEW lesions are unrelated conditions are noted at that time, you can code those as well... even if benign or asymptomatic.  

On the hother hand, if the condition has reoccurred, you can code it again (because it now exists again).

Again, you don't code a condition that *no longer exists!*. It's very clear in the guidelines.

Simplifying all this... for the E/M visit stated in the original post, after the postop period has expired, the personal history codes is perfectly acceptable for any follow-up E/M.  Whether benign or malignant.

I can provide additional instructions/citations from the American Academy of Dermatology if needed.

Otherwise, I'm done.


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## thomas7331 (Apr 14, 2017)

Debra's point is correct that the diagnosis must be selected based on the documentation.  The original question asked "Which ICD-10 Code(s) are used as a diagnosis for a patient seen for a follow-up from an excision of a lesion after the global period?"  This question can't be answered correctly without reviewing the individual record.  A coder cannot make the determination that a malignancy no longer exists simply because the visit is a follow-up after an excision.


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## ellzeycoding (Apr 14, 2017)

I will argue that after a postop period has expired (10 or 90 days depending if repair was done), pathology should be definitive by this point and you would know whether the lesion was removed with clean margins and whether the malignant lesion still exists.

Debra's quote  _"If the path result was a malignancy then the condition does still exist."  _

Not true if that particular lesion was removed in total.

ICD-10 states that if it has been completely removed via excision (and you would know that via path), then use the personal history code, not the original malignany diagnosis.  It can't be more clear.


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## mitchellde (Apr 14, 2017)

Not all malignancy is completely removed via excision even if the path indicates clear margins.  Not all path reports state this , I code pathology and rarely see this stated.  Depending on location and type of malignancy the provide may take several different directions.  One may be reexcision but not always. Also patient overall health and preference plays a part.  So until the provider indicates there is no evidence of remaining disease it is still a malignancy. An insitu malignancy once excised is immediately history of.  A benign result is coded as follow up.  Any response other than malignant is coded as follow up. A malignant path must wait for the provider to determine what comes next.  Just because the visible lesion has been removed does not mean the malignancy has been completely removed.  Just because the visible lesion is no longer there does not mean the neoplasm no longer exists.  There are many fine points to a path report and couched between the layers within the microscopic is a ton of information the provider uses to make a definitive determination.  The average coder has not the knowledge to interpret this information and should never make the attempt.


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## ellzeycoding (Apr 14, 2017)

Understand your point, but this is not the recommendation of ICD-10 Guidelnes for code selection purposes of after excision of malignant lesions and also not the recomendation of the American Academy of Dermatology.  

Both state to use the personal history code for follow up examinations after a malignant lesion has been excised (and assuming margins are clear per path).  Yes, path should show margins are clear (or not).  Dermatologist use this to determine if re-excision is necessary.

_"d. Primary malignancy previously excised

When a primary malignancy has been previously excised or eradicated from its site and there is *no further treatment *directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the *former site *of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code."_

So I respectfully disagree.


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## ellzeycoding (Apr 14, 2017)

From the AAD Derm Coding Consult...

See attachment


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## daedolos (Apr 14, 2017)

ellzeycoding said:


> Understand your point, but this is not the recommendation of ICD-10 Guidelnes for code selection purposes of after excision of malignant lesions and also not the recomendation of the American Academy of Dermatology.
> 
> Both state to use the personal history code for follow up examinations after a malignant lesion has been excised (and assuming margins are clear per path).  Yes, path should show margins are clear (or not).  Dermatologist use this to determine if re-excision is necessary.
> 
> ...





Just curious. Have you had any claims bounce back?

Peace
@_?
I'm looking at this global period issue from a billing standpoint.


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## mitchellde (Apr 15, 2017)

The problem I am having is that you are confusing what the guidelines are are saying.  The guidelines specify when a malignancy is completely removed. It specifically does not state "when a malignant lesion is excised".  Removal of the lesion does not necessarily mean the malignancy has been removed.  That is up to the provider to determine after a thorough review of the pathology report.  None of the path reports I have coded state " margins are clear". Or anything remotely remotely close to that.  However within the microscopic there will be indications the provider can use to make that determination.


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## ellzeycoding (Apr 15, 2017)

Agree to disagree then.  (I feel like I'm just banging my head into the wall at this point).

You're focusing on a specific anomaly (i.e. the rare event that a provider didn't remove all of a maligant lesions (e.g., BCC, SCC, melanoma, merkel cell, etc.).  By the end of the postop period, after path has returned and reviewed, it should be known at this point.  If during this E/M visit after postop has ended (again, per the original question) it's determined that the tumor is still present or wasn't completely removed, the patient would still have this condition and it would be appropriately coded as so.

But for all intents and purposes, after removal (excision, Mohs, etc.), and absent any indications via path, dermatologists handle this as previously treated condition, not an active condition. You don't code a condition that is no longer present.  Therefore, personal history codes are used.  Been this way forever in the world of dermatology.

My position is backed by the ICD-10 guidelines and the AAD.  After 25 years of educating providers, billing claims, and coding professionally, I'll stand by it.


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## mitchellde (Apr 15, 2017)

ellzeycoding said:


> From the AAD Derm Coding Consult...
> 
> See attachment



In your attachment I am assuming you are referring to the example regarding the 6 month follow for the melanoma.  In this example it is specifically documented as " malignancy was previously excised or eradicated, no evidence of existing malignancy".  In this case due to the documentation it is coded as follow up and history of.
However there was no mention in the original post as to what the documentation would state.  It was a generic statement of how to code a follow up and I gave an acceptable generic answer.  The final word is it all depends on the documentatio.  If the provider does not indicate no evidence of disease then the coder must code the maglinant diagnosis.  You cannot assume that removal of the malignant lesion is removal of the malignancy.


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