Revenue Cycle Insider

Question: A patient came back to us following palliative chemotherapy for primary liver cancer. Is this regarded as follow-up care or aftercare, and what is the correct way to code this scenario?

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Answer: In encounters like this, where a patient is receiving ongoing treatment for a cancer that still exists, ICD-10-CM guidelines define the care provided to the patient as aftercare. Per guidelines I.C.21.c.7 and 8, aftercare describes “ongoing care of a healing condition or its sequelae” beginning “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,” according to ICD-10-CM Guideline I.C.21.c.7.

This is in contrast to follow-up care, which consists of “continuing surveillance following completed treatment of a disease, condition, or injury,” according to the guideline. Follow-up care implies “the condition has been fully treated and no longer exists” and there is no ongoing treatment for the condition.

To code aftercare following radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm, Guideline I.C.21.c.7 tells you to use Z51.0 (Encounter for antineoplastic radiation therapy) and codes from Z51.1- (Encounter for antineoplastic chemotherapy and immunotherapy) “when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm.”

The aftercare guideline also tells you that “aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification.” The guideline also notes that the aftercare codes “are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm.”

So, for a patient receiving palliative chemotherapy for primary liver cancer, you would begin by using Z51.11 (Encounter for antineoplastic chemotherapy) as the first-listed code with a code such as C22.8 (Malignant neoplasm of liver, primary, unspecified as to type) for the diagnosis. And as the example indicates the treatment is palliative care, you may also add Z51.5 (Encounter for palliative care), which should be listed as the second or third diagnosis code.

Remember: You can use more than one code from the Z51.0 and Z51.1- categories if the patient receives more than one kind of antineoplastic therapy.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC