Otolaryngology Coding Alert

Question: A patient returned to our provider for a routine follow-up after undergoing a bilateral myringotomy with tubes (BMT). The tubes were placed 13 months ago, and at this appointment, the patient’s ears appeared stable and the patient seemed to be hearing well. Otitis media and accumulation of fluid were no longer present, and there was no evidence of recent drainage.

Should we use Z09 or Z48.810 to document this encounter?

Kansas subscriber

Answer: The most appropriate code to use in this situation would be Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm).

Here’s why.

The block notes for Z40-Z53 (Encounters for other specific health care) state the codes in this group “may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state.”

This reflects ICD-10 guideline I.C.21.c.8, which tells you follow-up care consists of “continuing surveillance following completed treatment of a disease, condition, or injury.” It implies “the condition has been fully treated and no longer exists.”

In other words, the key to defining follow-up care as far as ICD-10 is concerned is to verify that:

• The condition no longer exists.
• There is no ongoing treatment for the condition.

Aftercare, however, begins “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,” according to ICD-10 guideline I.C.21.c.7. Guideline I.C.21.c.8 further clarifies that aftercare “explain[s] ongoing care of a healing condition or its sequelae.”

The encounter you describe is a surveillance encounter after treatment. The patient is not undergoing treatment, the condition has resolved, and the encounter did not involve continuing treatment, which is aftercare or prophylactic care per ICD-10.

Because of that, you would not use Z48.810 (Encounter for surgical aftercare following surgery on the sense organs). Instead, Z09 describes the situation perfectly.