Internal Medicine Coding Alert

Question: A patient we have been treating for a severe case of eczema came back to our practice for a follow-up appointment. Our provider determined that the treatment had been effective and that the condition had cleared up. However, the physician also made another appointment to make sure that the condition had fully resolved and that there were no problems with the side effects of using the topical steroid. Should we use an encounter code to show that the treatment had been completed at this recent appointment, or should we wait until the next appointment before reporting the treatment's completion?

Oregon Subscriber

Answer: The answer to your question lies in the reason for patient's most recent visit. At this visit, your provider is still treating your patient for the condition even though the physician has reported that the condition has now ended. So, you would continue to code the diagnoses - in this case using a code from the dermatitis and eczema (L20-L30) series, such as L30.9 (Dermatitis, unspecified) - even though your provider determined that the eczema had cleared up.

It would only be at the next visit that you would document the completion of the treatment by using Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm), as the purpose of the visit has changed. Your patient is no longer coming in for treatment and is now confirming the end of the condition and the completion of the treatment with your provider.

Once you code Z09, however, you must also follow the ICD-10-CM guidelines that accompany that code, and report "any additional code to identify any applicable history of disease code (Z86.-. Z87.-)." In this case, this would mean documenting Z87.2 (Personal history of diseases of the skin and subcutaneous tissue). 

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