Wiki Z09 follow-up for resolved condition, but pt has other active chronic conditions

[lilleyea]

I have a question regarding the correct usage of Z09.

Say the patient is seeing their PCP after hospital discharge for resolved chest pain as the main reason for the visit. While the patient is in the office the doctor also addresses the patient's chronic problems.

Would it be appropriate to use Z09 as the first diagnosis with history of chest pain as the secondary, followed by the chronic conditions? Or since the chronic conditions are still active then Z09 should not be used?

Thank you for any guidance on this

 

[erjones147]

Based on what you wrote, I would say it depends on what's in the Chief Complaint and/or HPI

To me, if a patient mentions conditions right up front, then it would be up to the PCP to determine the reason for the visit - Z09 may or may not be the main reason to the provider

If acute conditions only came up in the exam or if the provider said, "While you're here, let's do an A1c to check your diabetes," then I would think the Z09 would be the best choice for the primary dx in your scenario

 

[tiffanyannd]

Another question on Z09

I work in an outpatient health center, and every so often I will come across claims where the provider is doing a follow up.

For example, the patient will be following up for an Upper Respiratory Infection. But in the progress notes the provider writes that this symptom is resolved.

So I am a bit confused what to do with these claims, as in outpatient you never code for things that are resolved, or probable ext.

I have in the past used Z09 with the code for the resolved symptom. Or I have used a history of code, for whatever the symptom was, with and without the Z09.

But both of those seem like the wrong thing to do. I'm wondering if these visits should even be billed, as nothing else is being addressed, and the exam is very focused on the resolved symptom.

Any help is appreciated.

 

[tag60]

Hi Tiffany, I don't see why these visits should not be billed, even if the condition is resolved. The provider is doing the work of assessing the patient and making the determination. I've read on this forum in the past, too, that it would be correct to code the resolved condition as a current condition (for example, URI) because at the time the appointment is made, it's not known if resolved or not. However, that was some time back and perhaps the Z09 code plus history code is preferred/correct way to do this since implementation of ICD-10. In any case, a follow-up visit with resolved condition is billable as long as documentation supports.