Don’t Let a Recheck Trip up Your Diagnosis Coding
Question: Our pediatrician asked a child to return for a checkup after completing treatment for acute otitis media. At the follow-up visit, the physician documented that the infection had completely resolved. Should we still report the otitis media diagnosis because it prompted the return visit, or should we report an ICD-10-CM follow-up examination code? AAPC Forum Participant Answer: When treatment is complete and the pediatrician confirms that the condition has resolved, you’ll report Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) rather than a code for the previously treated condition. Code Z09 is appropriate for the practitioner to observe the completed treatment and instructs you to use an additional code to identify any applicable history of disease, when appropriate. Don't confuse follow-up with aftercare: Aftercare applies when the patient continues to receive care during the healing or recovery phase, whereas a follow-up examination generally occurs after treatment has been completed. This difference matters because Z09 specifically excludes certain encounters for aftercare following medical care. Make note: The key is determining whether the condition still exists. A follow-up examination occurs after treatment has been completed and is intended to determine whether the condition has returned or remains resolved. Don’t report the acute otitis media as though it is still present simply because it was the reason for the return visit. If the pediatrician had determined at the recheck that the infection persisted or had recurred, however, you would report the appropriate diagnosis for the active condition instead. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
