Part B Insider (Multispecialty) Coding Alert

Published on Mon Dec 07, 2015 PDF

Question: Our doctors sometimes see patients for follow-up visits after evaluating a problem that required no treatment, and we are unsure of which ICD-10 code to report for these. Although Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) is close, we’d rather have a follow-up code that describes a service that was not “after treatment.” Can you advise on whether there is such a code?

Answer: There is not such a code in ICD-10, and you are correct in selecting Z09 as the most accurate code for this service.

Although the code’s descriptor does say “after completed treatment,” remember that “treatment” can include supportive care, such as fluids, ibuprofen, rest, and monitoring. If you are checking in on a patient who had a bout of vomiting and you want to make sure she’s feeling better following a previous visit during which the physician only prescribed rest and monitoring, you can use Z09.

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