Neurosurgery Coding Alert

Question: A female patient who has successfully undergone surgery for removal of a brain neoplasm visited the surgeon for evaluation of wound and neurological deficits. Which code should we report?

Ohio Subscriber

Answer: Rather than report an acute diagnosis of brain neoplasm (for instance, C71.1,  Malignant neoplasm of frontal lobe) — which is inaccurate — you should select Z48.3 (Aftercare following surgery for neoplasm) to reflect that the checkup is for a condition that is no longer acute.

“Aftercare visit codes cover situations 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,” per the ICD-10 Official Guidelines for Coding and Reporting.