Wiki Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

[mmckowen]

Curious as to the appropriateness of using Z09 for Cardiac Rehab dx as this is not a f/u examination but more a continuation of txt.
Am I missing something?
Thank you!
Maureen McKowen, MBA HA, RHIA
Clinical Review Analyst
Corporate Compliance

 

[sls314]

Curious as to the appropriateness of using Z09 for Cardiac Rehab dx as this is not a f/u examination but more a continuation of txt.
Am I missing something?
Thank you!
Maureen McKowen, MBA HA, RHIA
Clinical Review Analyst
Corporate Compliance

Z08 and Z09 codes are used for medical surveillance following completed treatment. The codes have a "Use additional code..." note to identify the applicable history of disease code.

Those codes are used to verify that treatment was successful and disease has not returned.

For example, I use the Z08 when patients are coming in 2 years post treatment with no signs of cancer, but the physician is following them once a year for 5 years to be sure it hasn't returned. I bill the Z08 + history of cancer diagnosis code. Z09 would be used in a similar way for non-cancer diagnoses.

Perhaps an aftercare diagnosis would be more appropriate for cardiac rehab? I'm not an expert on cardiac rehab, so don't take my word for it. But reviewing the pasted section below from the ICD-10 guidelines for the follow up codes would incline me to at least explore the aftercare section

From the ICD-10 guidelines...

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