Ob-Gyn Coding Alert

Question: A patient is 2+ years since completion of treatment for endometrial cancer and she is being seen by our ob-gyn for surveillance visits. Her original surgery was a TLH and then chemo, but she is no longer undergoing treatment. Should I report Z85.42 or Z08 for this patient? My ob-gyn documented:

• “She is 2+ years since completion of treatment in Feb 2020. For now we continue to recommend surveillance, next exam in 4 months.
• Pelvic exams and review of symptoms now every 6 months until she is 5 years out then annually. Routine PAP smears are not typically recommended as part of surveillance.
• CA-125 is a sensitive marker for this patient. We plan to repeat in 3 months prior to next visit.”

South Carolina Subscriber

Answer: According to ICD-10 guidelines, you will use follow-up codes (such as Z08) to explain continuing surveillance following completed treatment of a disease, condition, or injury. In other words, the condition has been fully treated and no longer exists. In addition, the guidelines state that you may report a history code to provide the full picture of the healed condition and its treatment. The instructions then indicate that you should list the follow-up code first, followed by the history code.

So in your scenario, your ICD-10 coding will be reported as Z08 (Medical surveillance following completed treatment) first, followed by Z85.42 (Personal history of malignant neoplasm of other parts of uterus).