Wiki Follow up for prostate cancer

[az2tn@yahoo.com]

Would a follow up for prostate cancer status post XRT in 2014 with normal PSA on this DOS be Z08 & Z85.46?

 

[brittneyxnicole]

Yes if no longer being treated. You could also add Z92.3 for the history of radiation therapy.

 

[natashalage]

What if pt comes for follow up Z08 and has a new problem

What if pt comes for follow up Z08 and has a new problem? Would you code Z08 + New problem or New problem + History of Dx (follow up condition)? Thank you.

 

[Jessim929]

What's the primary focus of the documentation? If they come in for a routine follow up but now has <insert random issue here> going on and the note focuses on discussing/diagnosing/getting a treatment plan in place for the random issue and the follow up becomes almost an offhand mention, I'd use the follow up diagnosis as secondary or whatever. If the focus of the note is the follow up with a brief "patient mentioned <issue> which will be addressed in further detail at a later visit", then I'd use the follow up diagnosis as primary.