Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z09 is a billable/specific and POA-exempt diagnosis code from the 2024 ICD-10-CM used to classify the following condition: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm .
Inclusion term
Medical surveillance following completed treatment
Use additional code
Code to identify any applicable history of disease code ( Z86.- , Z87.- )
Type 1 excludes
Aftercare following medical care ( Z43-Z49 , Z51 )
Surveillance of contraception ( Z30.4- )
Surveillance of prosthetic and other medical devices ( Z44-Z46 )
Code changed
- code to identify any applicable history of disease code (Z86.-. Z87.-)
- code to identify any applicable history of disease code (Z86.-, Z87.-)
E/M office visit coding series: Tips for time-based coding
Series overview:
- How to code visits in one or two questions
- Tips for time-based coding
- Problems are the coding key
- Code the visit by just looking at your assessment and plan
The 2021 E/M office visit coding changes allow physicians to code visits based solely on total time, which is defined as the entire time you spent caring for the patient on the date of the visit. It includes your time before the visit reviewing the chart, the actual face-to-face visit with the patient, and all the time you spend after the visit on documentation, reviewing studies, calling the patient or family, etc. — as long as you do it before midnight on the date of service. It does not include time you spend on other dates, time you spend doing procedures that are separately billed, or time your nurses or other staff spend.
For established patients, it may be helpful to remember what I call the “30/40 minute rule”: Level 4 visits start at 30 minutes, and level 5 visits start at 40 minutes. (For more time-based coding tips, see this previous “Getting Paid” post .)
Documentation tips
Documentation is important if you are going to base your coding on time. Rather than just writing “Total time spent was XX minutes,” it’s useful to explain what was included in the time, especially now that patients have access to your notes. They may not understand that the time you’ve listed includes more than just the face-to-face portion of the visit. Here’s an example of a well-explained note: “ Total time spent caring for the patient today was XX minutes. This includes time spent before the visit reviewing the chart, time spent during the visit, and time spent after the visit on documentation, etc.”
A little extra explanation may also be useful in case of an audit. For example, if you did a procedure during a visit and billed for it separately, you might want to add, “ Time excludes procedure time ” just to make sure there’s no confusion about that.
Take care with EHR time calculators
EHR time calculators that document the time a patient’s chart is open can be helpful if you’re using time for coding. But relying on them too much can cause problems. If you don’t remember to open the chart as soon as you enter the room and keep it open for the entire visit, it’s not going to accurately reflect the time you actually spent. If you can access the chart by smartphone as well as computer, make sure your EHR tracks time on both devices or, again, you will have an undercount.
Over-reliance on time calculators could also cause you to overstate your total time if your EHR double-counts time when the chart is open in your office and in the exam room simultaneously, or if it falsely counts time when the patient’s chart is tabbed but not opened.
Long visits (prolonged services)
Unfortunately, depending on the payer, there are currently different prolonged services codes, with different time ranges, for visits that exceed level 5 in total time. Medicare and some private insurance companies use G2212, which is for established patient visits of 69 minutes or more and new patient visits of 89 minutes or more. Other insurers use CPT code 99417, which is for established patient visits of 55 minutes or more and new patient visits of 75 minutes or more. With both codes, prolonged services are billed in 15-minute increments and pay 0.6 work Relative Value Units for each 15 minutes. Below is a chart you can quickly reference for time-based coding, including prolonged services.
— Keith W. Millette, MD, FAAFP, RPH
Posted on Oct. 31, 2022
- Chronic care
- Medicare/Medicaid
- Physician compensation
- Practice management
- Reimbursement
- Value-based payment
Other Blogs
- Quick Tips from FPM journal
- AFP Community Blog
- Fresh Perspectives
- In the Trenches
- Leader Voices
- RSS ( About RSS )
Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use .
Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.
The portal uses cookies to provide service functions such as “Bookmark” and to improve website usage. Information and opt-out options can be found in the cookie settings in the privacy policy .
Z09.9: Follow-up examination after unspecified treatment for other conditions
You were given a follow-up examination after a treatment..
An examination after a treatment makes it possible to find out whether the treatment was successful. The examination is also to see whether the patient has come through the treatment well.
Additional indicator
On medical documents, the ICD code is often appended by letters that indicate the diagnostic certainty or the affected side of the body.
- G: Confirmed diagnosis
- V: Tentative diagnosis
- Z: Condition after
- A: Excluded diagnosis
- B: Both sides
This information is not intended for self-diagnosis and does not replace professional medical advice from a doctor. If you find an ICD code on a personal medical document, please also note the additional indicator used for diagnostic confidence. Your doctor will assist you with any health-related questions and explain the ICD diagnosis code to you in a direct consultation if necessary.
Provided by the non-profit organization “Was hab’ ich?” gemeinnützige GmbH on behalf of the Federal Ministry of Health (BMG).
In outpatient care, the ICD code on medical documents is always appended with a diagnostic confidence indicator (A, G, V or Z): A (excluded diagnosis), G (confirmed diagnosis), V (tentative diagnosis) and Z (condition after a confirmed diagnosis).
IMAGES
VIDEO
COMMENTS
ICD 10 code for Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm. Get free rules, notes, crosswalks, synonyms, history for ICD-10 code Z09. ... Convert Z09 to ICD-9-CM. Code History. 2016 (effective 10/1/2015): New code (first year of non-draft ICD-10-CM)
I would code this encounter like this: If the chief complaint is patient is coming in for follow up for pharyngitis. Z09, Z87.09 (personal history of, if the Pharyngitis is resolved.) then lastly F41.9 because that was not the main reason for the encounter, that is a new problem that was addressed at the follow up visit.
ICD-10 code Z09 for Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm is a medical classifica. Select. Code Sets; ... 502970, member: 247821"] For guidelines 9/2020-10/2021 ) Follow-up visits after COVID-19 infection has resolved For individuals who previously had COVID-19 and are being ...
V67.00 Follow-up examination, following surgery, unspecified convert V67.00 to ICD-10-CM. V67.01 Following surgery, follow-up vaginal pap smear convert V67.01 to ICD-10-CM. V67.09 Follow-up examination, following other surgery convert V67.09 to ICD-10-CM. V67.1 Follow-up examination, following radiotherapy convert V67.1 to ICD-10-CM.
ICD-9-CM Code: V67.09 - Follow-up surgery NEC Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code. ICD-9-CM Code: V67.1 - Radiotherapy follow-up Approximate Flag - The approximate mapping means there is not an ...
Therefore your ICD‐10‐CM codes are Z09 (Encounter for follow‐up exam after completed treatment for conditions other than malignant neoplasm) and if you choose to also code the personal history, report Z86.69 (Personal history of other diseases of the nervous system and sense organs) as a secondary code. Q.
Unspecified follow-up examination. ICD-9-CM V67.9 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, V67.9 should only be used for claims with a date of service on or before September 30, 2015. For claims with a date of service on or after October 1, 2015, use an equivalent ICD-10-CM code (or ...
ICD-10-CM Alphabetical Index References for 'Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm' The ICD-10-CM Alphabetical Index links the below-listed medical terms to the ICD code Z09. Click on any term below to browse the alphabetical index.
Z09 is a billable/specific and POA-exempt diagnosis code from the 2024 ICD-10-CM used to classify the following condition: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.. Inclusion term. Medical surveillance following completed treatment. Use additional code. Code to identify any applicable history of disease code (Z86.-, Z87.-
Unspecified follow-up examination. (V67.9) ICD-9 code V67.9 for Unspecified follow-up examination is a medical classification as listed by WHO under the range -PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER CIRCUMSTANCES (V60-V69).
Step 1: Total time. Think time first. If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if ...
Other insurers use CPT code 99417, which is for established patient visits of 55 minutes or more and new patient visits of 75 minutes or more. With both codes, prolonged services are billed in 15 ...
(j) Follow-up visits after COVID-19 infection has resolved For individuals who previously had COVID-19 and are being seen for follow-up evaluation, and COVID-19 test results are negative, assign codes Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and Z86.16, Personal history of
The patient's visit marks one month following a thyroid lobectomy to remove a malignant nodule. The MRI reveals no traces of malignancy. You might assume that, using the ICD-10-CM guidelines in this scenario, the answer is straightforward. However, you shouldn't necessarily jump to report Z08 (Encounter for follow-up examination after ...
ICD-9-CM Code: V67.01 - Follow-up vag pap smear Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code. ICD-9-CM Code: V67.1 - Radiotherapy follow-up Approximate Flag - The approximate mapping means there is not an ...
Short description: Follow-up exam NOS. ICD-9-CM V67.9 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, V67.9 should only be used for claims with a date of service on or before September 30, 2015. For claims with a date of service on or after October 1, 2015, use an equivalent ICD-10-CM code ...
Provided by the non-profit organization "Was hab' ich?" gemeinnützige GmbH on behalf of the Federal Ministry of Health (BMG). This page provides explanations for the ICD diagnosis code "Z09.9 Follow-up examination after unspecified treatment for other conditions" and its subcategories.
The V code can be used as secondary to indicate a follow-up visit, he says. In fact, the 1999 ICD-9-CM tabular list indicates that code V67.9 is a non-specific code and used alone does not reflect enough information to support the visit. The guidelines published by HCFA and the AHA are meant to guide coders, but, in fact, payer policy may ...
Contrast the follow-up codes to the main group of aftercare codes, Z42-Z51, which ICD-10 clarifies "are for patients who have already been treated for a disease or injury, but who are receiving aftercare.". These codes are much more detailed. in nature and include such ob-gyn-oriented encounters as Z44.8 (Encounter for fitting and ...
May 12, 2010. #5. I disagree! If the diagnosis is resolved, you can't code it. You would report the appropriate V code for the follow-up (from the V67 category), then as a secondary code, you would report a V code for history of the condition that you are following up for. This is per the ICD-9-CM guidelines. Last edited: May 12, 2010.