Primary Care Coding Alert
Resolve This Condition Conclusion Coding Conundrum
Question: One of our patients was admitted to the emergency room (ER) for cellulitis, then came to us a week later for a follow-up visit. Our provider noted that the condition had been resolved. I coded Z09 and Z87.2 for the encounter, but I am wondering whether the timeframe for the illness is sufficient to use a “history of” code? Ohio Subscriber Answer: According to ICD-10 guidelines (I.C.21.c.4), “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.” The guidelines also note personal history codes may be used in conjunction with follow-up codes. The ICD-10 guidelines do not specify how long it must be since the medical condition existed (i.e. how far in the past is “past”), and in that sense, there really is no timeframe for using the code. If your provider has documented the condition has been resolved, then that is all you need. Consequently, your use of Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) and Z87.2 (Personal history of diseases of the skin and subcutaneous tissue) in this encounter is correct.
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Resolve This Condition Conclusion Coding Conundrum
Question: One of our patients was admitted to the emergency room (ER) for cellulitis, then [...]
