Wiki Z09

[allison_w_99]

Has anyone had experience applying this code? When it is appropriate to use for an asymptomatic patient? Could it be used for a f/u exam the day after a procedure with no global period in an inpatient environment for physician services for a condition that no longer exists?

ie. an otherwise young healthy person presents with acute epigastric pain and n/v, is admitted and found to have CBD stones on a CT. The patient has an ERCP the next day and no CBD stones exist after the procedure is complete. The next day in the hospital the physician performs a brief f/u visit (meeting requirements for 99231) and the patient is completely asymptomatic and has no complaints except for a little bit of pain that is expected after the procedure.

I see nothing wrong with using Z09 for the above situation. Thoughts?

 

[amymeyers01]

I am not 100% sure about this and don't know where to send you to find authoritative guidance- but my understanding of this code is that it wouldn't be used until a follow up visit in the doctor's office as an outpatient after being discharged from the hospital. As long as the patient is still in the hospital due to the surgery, I would consider it to be surgical aftercare of the condition. She technically is still receiving care for the condition for the length of her hospital stay unless a new problem presents during her stay which is unrelated to the original condition or complications of surgery. I would look for the doctor to document completed care after complete healing from surgery.

Amy Meyers, CPC, ICD-10 certified

 

[mitchellde]

I see no problem using this code for a follow up in the inpatient setting. Z09 indicates the condition no longer exists and is not being treated.

 

[NeoCoder116]

How do you feel about using it in the case of a patient with a confirmed streptococcal sore throat and comes back after the antibiotics have run out and is checked by the PCP? If the PCP does an in-house strep test, which is negative, wouldn't be a good example to use the Z09 (in the follow up visit)?

 

[rykin7609]

In the ICD10 Guidelines C. Chapter-Specific Coding Guidelines, Chapter 21.c.8, "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." The Guidelines also go on to state not to confuse the Aftercare Z codes with the Follow-up Z codes. Which I have unfortunately done from time to time.

Allana