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Coding resolved conditions ALONG WITH current conditions


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I know that follow-up visits for resolved conditions are to be coded with the follow-up code (typically Z09) and then the history code for the now-resolved condition.

My question is:

How do you code / sequence codes for a visit that includes BOTH resolved AND ongoing and/or chronic conditions?​

Here are a few examples of what I mean, where I am unsure of how you would code / sequence these...

  1. Patient is seen in follow-up for:
    B/l foot pain due to an injury
    Sleep disorder due to shift work

    The sleep disorder has resolved because the patient switched their shift at work, but the foot pain continues as the injury is still healing.

  2. Patient is seen in follow-up for:

    All URI symptoms have resolved. Patient mentions dysuria and is given antibiotics for UTI.

  3. Patient is seen in follow-up for:
    Final wound check from laceration
    Hypertension (already diagnosed - chronic)

    Wound is completely healed. Hypertension is stable.


4. Patient is seen in follow-up for:
COPD exacerbation

Exacerbation has resolved. COPD is stable.

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I am not having any luck finding guidance on this, so I really appreciate any help you can give!! Thank you!!
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True Blue
Best answers
I think that this is a 'grey area' of coding and there is not a lot of official guidance on this, and you'll need to be primarily guided by your provider's documentation on the status of these conditions. That said, I would make a coupe of suggestions, based on my own experience.

First, my understanding of the Z09 code is that it is not meant to be a catch-all code for any follow-up care, but rather is designed for use in a 'surveillance' situation when a particular condition has a risk of recurrence and requires future monitoring for some time beyond the resolution of the condition. The entry under this code is "Medical surveillance following completed treatment" and the key word here is 'completed' which indicates that this is a visit is separated by some time after the patient was last seen by the provider and was deemed to have completed their course of treatment for that condition. Generally speaking, if the patient was seen for a condition at the previous visit, and was simply instructed to return for follow-up so that the provider could evaluate their response to treatment, then I would code that condition and not use follow-up and history codes even if the provider, at that visit, gives the assessment that the condition is resolved. This is because that final visit is still part of the treatment for the condition - if a follow-up was part of the original treatment plan, then it does not meet the definition of a visit 'following completed treatment'. Once resolved, then at any future visits where there is no recurrence, that condition can then be coded as history if it is documented as a factor in the treatment at that encounter. I think this is standard practice for coders that I have worked with, though I can't point to a specific place where this guidance is given.

The exception to this would be for your injury codes, e.g. your foot injury and laceration conditions above, where you would use the appropriate 7th character for the code to describe the phase of the treatment and per guidelines would never use a follow-up code.

Your COPD example I would handle a little differently, because exacerbation is not a separate condition from COPD. So the condition has not resolved, it has just changed in nature such that a different code is warranted, so I would code the provider's assessment accordingly as COPD without exacerbation if that is the documented condition that exists at the time of that visit.

Last, I'd just add that sequencing is not really an issue. As per the ICD-10 guidelines, you'll need to choose your first-listed diagnosis as being the "diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided" and if two conditions are both equally responsible, you may use either. Additional codes do not have to be sequenced in any particular order, except for cases where the coding guidelines for a specific code contain a 'code first' or 'use additional code' instruction.

Hope this will help some. I'd be interested to hear if any of the ICD-10 experts on the forum have any additional input.
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