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May 1, 2024
Aftercare and Follow-Up: ICD-10 Coding
Aftercare visit codes are assigned in situations in which the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.
ICD-10 makes two important points about the use of aftercare codes in the final chapter.
- The aftercare Z code should not be used if treatment is directed at a current, acute disease.
- The aftercare Z codes should not be used for aftercare for injuries.
Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title.
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Last revised April 9, 2024 - Betsy Nicoletti Tags: general surgery_diagnosis coding , ICD-10 coding
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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.
In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.
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Type your tag names separated by a space and hit enter
- Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
- Medical surveillance following completed treatment
Use Additional Code
- code to identify any applicable history of disease code ( Z86. -, Z87. -)
Not Coded Here
- aftercare following medical care ( Z43 - Z49 , Z51 )
- surveillance of contraception ( Z30.4 -)
- surveillance of prosthetic and other medical devices ( Z44 - Z46 )
- Z00 - Encounter for general examination without complaint, suspected or reported diagnosis
- Z01 - Encounter for other special examination without complaint, suspected or reported diagnosis
- Z02 - Encounter for administrative examination
- Z03 - Encounter for medical observation for suspected diseases and conditions ruled out
- Z04 - Encounter for examination and observation for other reasons
- Z05 - Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out
- Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm
- Z11 - Encounter for screening for infectious and parasitic diseases
- Z12 - Encounter for screening for malignant neoplasms
- Z13 - Encounter for screening for other diseases and disorders
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Transitional Care Management
What is medicare transitional care management (tcm).
Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.
The two CPT codes used to report TCM services are:
- CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge
- CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge
Requirements and Components for TCM
- Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
- Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
- Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
- Obtain and review discharge information.
- Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
- Educate the beneficiary, family member, caregiver, and/or guardian.
- Establish or re-establish referrals with community providers and services, if necessary.
- Assist in scheduling follow-up visits with providers and services, if necessary.
Discharge from any of the following:
- Inpatient acute care hospital
- Long-term acute care hospital
- Skilled nursing facility/nursing facility
- Inpatient rehabilitation facility
- Hospital observation status or partial hospitalization
Health Care Professionals Who May Furnish and Bill TCM Services:
- Physician (any specialty)
- Clinical nurse specialist (CNS)
- Nurse practitioner (NP)
- Physician assistant (PA)
- Certified nurse midwife
Non-physicians must legally be authorized and qualified to provide TCM services in the state in which the services are furnished.
Learn How Coordinated Care Benefits Patients, Quality Payment Program (QPP) Performance and Your Bottom Line
Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service.
Read more about transitional care management in the Making Sense of MACRA: Aligning Transitional Care Management (TCM) with the Quality Payment Program (QPP) supplement (PDF)
AAFP’s Position on TCM Services
The AAFP’s advocacy efforts have helped pave the way for Medicare payment for TCM services, giving family physicians an opportunity to be paid to coordinate care for Medicare beneficiaries as they transition between settings. We believe that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.
What You Need to Know
As health care moves from volume to value, TCM services will be increasingly important. These services ensure patients receive the care they need immediately after a discharge from a hospital or other health care facility. Continuity of care provides a smooth transition for patients that improves care and quality of life, and helps prevent unnecessary readmission, thereby reducing costs.
Approaches to Help Your Practice Get Started
- Identify hospitals and emergency departments (EDs) responsible for most patients’ hospitalizations. With the shared goal of decreasing readmissions, develop a relationship with those hospitals to improve timeliness of notification, so the practice can reach out to patients within two business days of discharge.
- Add this service to decrease cost of care by reducing unnecessary readmissions.
- Add this service after the annual wellness visit and chronic care management (CCM) as the volume and associated revenue of this service is hard to anticipate.
Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.
Hospital Follow Up ICD-10-CM Codes | 2023
Read this short guide to learn about Hospital Follow Up ICD codes you can use!
By Nate Lacson on Feb 29, 2024.
Fact Checked by Nate Lacson.
What Hospital Follow Up ICD-10 codes can I use?
If you’re looking for Hospital Follow Up ICD codes , you must adjust your search term. There are ICD-10 codes for what you’re looking for, but they don’t use hospital follow-up. Instead, ICD-10 codes phrase it as an encounter for a follow-up examination.
There are two ICD-10 codes for it:
- Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm
- Z09 - Encounter for follow-up examination after treatment for conditions other than malignant neoplasm .
These codes are meant to be used on patients who have either completed cancer treatment (Z08) or a non-cancer problem (Z09) and are visiting a healthcare provider for a post-treatment follow-up examination.
Please note that these are unacceptable as principal diagnoses because they’re meant to designate that patients attend follow-up examinations.
Are these Hospital Follow Up ICD-10 codes billable?
Yes. Despite being unacceptable as principal diagnoses, these ICD-10 codes for Hospital Follow Up are valid in general and billable.
Clinical information about Hospital Follow-ups:
Hospital follow-ups are standard for patients discharged from the hospital after being treated. These follow-ups monitor patient conditions and provide routine medical care and support to ensure their recovery.
The nature of hospital follow-ups will vary from patient to patient because they will be based on what they were treated for.
Some might need to attend hospital follow-ups to have their surgical wounds checked to check for any infections or complications.
Some might need to attend these follow-ups to check for any remaining cancer cells that need to be destroyed or to monitor patients in case cancer re-emerges.
Some might need to attend follow-ups for short education sessions to learn how to manage permanent conditions and disabilities.
Synonyms include:
- Medical surveillance following completed treatment
- Aftercare following medical care
- Post-hospital follow-up
- Post-discharge follow-up
- Routine medical examination post-discharge
- Patient monitoring
- Patient monitoring post-discharge
- Hospital follow up ICD 10
- ICD 10 hospital follow up
- ICD 10 code for hospital follow up
- ICD-10 hospital follow-up 7 days
- Hospital discharge follow up ICD 10
Commonly asked questions
It depends on what the patient was treated for. Some might have to return for a follow-up just a week after discharge. Some might be scheduled three to five months later after being discharged.
Healthcare professionals will ask patients how they’ve felt after being discharged, apply any treatment needed to ensure a smooth recovery, and determine if treatment plans need to be adjusted.
It’s within the patient’s right not to attend a hospital follow-up. Healthcare professionals should still exercise due diligence and remind patients or reschedule, especially if their condition needs routine care.
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Difference Between Aftercare And Followup ICD 10 Codes
“Aftercare” ICD-10 codes are used to indicate medical services that are provided to a patient after the active phase of treatment has ended. These services may include ongoing monitoring of the patient’s condition, rehabilitation, and support to ensure that the patient’s recovery progresses smoothly. Examples of aftercare codes include Z51.89 (encounter for other specified aftercare), Z51.89 (encounter for orthopedic aftercare), and Z51.89 (encounter for urologic aftercare).
On the other hand, “follow-up” ICD-10 codes are used to indicate medical services that are provided to a patient to monitor the patient’s condition or progress after a prior medical encounter, such as a procedure or surgery. These services may include follow-up appointments, lab tests, imaging studies, and other procedures to monitor the patient’s recovery. Examples of follow-up codes include Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm), Z48.89 (encounter for other specified aftercare following surgical treatment), and Z09 (encounter for follow-up examination after completed treatment for malignant neoplasm).
In summary, aftercare codes refer to ongoing medical services provided to a patient after the active phase of treatment has ended, while follow-up codes refer to medical services provided to monitor a patient’s condition or progress after a prior medical encounter.
What the Aftercare? How to Use Z Codes in ICD-10
Let’s talk about Z codes in ICD-10—and what they have to do with post-surgical aftercare.
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Rehab therapists are restoration specialists. Not only do they work to restore musculoskeletal function after an illness or injury, but they also restore patients’ confidence in their movement and functional capabilities. In most cases, therapists see patients after they’ve experienced some type of disruptive event—like an injury, an illness, or a surgical procedure. But that doesn’t mean therapists should exclusively use aftercare codes, as Z codes in ICD-10 apply only in very select circumstances.
So, when it comes to how to use Z codes in aftercare, rehab therapists should keep the following advice in mind.
Aftercare Z codes in ICD-10 are not meant to be used with seven-character codes.
ICD-10 introduced the seventh character to streamline the way providers denote different encounter types—namely, specific situations involving active treatment versus those involving subsequent care. However, not all ICD-10 diagnosis codes include the option to add a seventh character. For example, most of the codes contained in chapter 13 of this resource (a.k.a. the musculoskeletal chapter) do not allow for seventh characters. And that makes sense considering that most of those codes represent conditions—including bone, joint, and muscle conditions that are recurrent or resulting from a healed injury—for which therapy treatment does progress in the same way it does for acute injuries.
Codes for acute injuries (mainly found in chapter 19) and fractures, however, do allow for seventh characters. And when you use the seventh character “D,” you are denoting that the patient is in the healing/recovery phase of their treatment. Essentially, you are indicating that these are situations where patients are receiving aftercare for the injury. Thus, you should not use aftercare codes in conjunction with injury codes, because doing so would be redundant.
Don’t let Z codes stump you ever again. Pick the right codes every time with the WebPT EMR’s intelligent ICD-10 selector.
Use z codes to code for surgical aftercare..
When a patient's health status necessitates continual care during a post-treatment healing or recovery phase—or when they require care for chronic symptoms that resulted from their original ailment—aftercare visit codes perfectly fit the bill. Z codes also apply to post-op care when the condition that precipitated the surgery no longer exists—but the patient still requires therapeutic care to return to a healthy level of function. These situations often provide common Z codes for therapists that include:
- Z47.89, Encounter for other orthopedic aftercare, and
- Z47.1, Aftercare following joint replacement surgery.
Remember, there are several orthopedic aftercare codes for specific surgeries—all of which you can find in this ICD-10 resource under Z47, Orthopedic aftercare.
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A single aftercare code might not be enough.
In specific situations where it’s appropriate to use Z codes in ICD-10, aftercare codes may be the principal first-listed diagnosis code—but that doesn’t mean the Z code should be the only diagnosis code listed for that patient. You should submit secondary codes—including other Z codes—when they can help you fully describe the patient’s situation in the most specific way possible.
For example, if you were treating a patient who had a total knee replacement, you would want to submit Z47.1, Aftercare following joint replacement surgery, as well as Z96.651 (to indicate that the joint replaced was the knee). Taking this one step further, let’s say the patient was receiving treatment for gait abnormality following a total knee replacement of the right knee due to osteoarthritis in that knee. Let’s also assume that, as a result of the surgery, the patient is no longer suffering from osteoarthritis. The appropriate codes for this scenario, according to this presentation , would be:
- ICD-10: Z47.1, Aftercare following surgery for joint replacement
- ICD-10: Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant
- ICD-10: R26.9 Abnormality, gait
If you’re still a little fuzzy on how to use Z codes in ICD-10, just remember that in most cases, you should only use aftercare codes if there’s no other way for you to express that a patient is on the “after” side of an aforementioned “before-and-after” event. So, go ahead and use an aftercare code after you’ve exhausted all other coding options. (See what I did there?)
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Note. Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'.This can arise in two main ways:
ICD-10 code Z09 for Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services . ... post: 501204, member: 145793"] Good Morning! I am trying to assist my hospital with ...
ICD-9-CM Code: V67.9 - Follow-up exam NOS 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. Code History. FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024;
October 1, 2017 Reporting Follow‐Up Encounters Q. How do I report an encounter for a follow‐up visit when the condition has been resolved? A. Per the ICD‐10‐CM guidelines "Do not code conditions that were previously treated and no longer exist." "The follow‐up codes (Z08, Z09, Z39) are used to explain continuing surveillance
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.
Aftercare and Follow-Up: ICD-10 Coding. Aftercare visit codes are assigned in situations in which the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. ICD-10 makes two important points about the use of aftercare codes ...
ICD-10-CM Diagnosis Code W94.11XA [convert to ICD-9-CM] Exposure to residence or prolonged visit at high altitude, initial encounter. Expsr to resdnce or prolonged visit at high altitude, init; Effects of high altitude. ICD-10-CM Diagnosis Code Z86. Personal history of certain other diseases. any follow-up examination after treatment (Z09) ICD ...
Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm answers are found in the ICD-10-CM powered by Unbound Medicine. Available for iPhone, iPad, Android, and Web. ... ICD-10-CM, 10th ed., Centers for Medicare and Medicaid Services and the National Center for Health Statistics, ...
Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and
I do not think Z09 is appropriate while the patient is still admitted to the hospital. Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm. Medical surveillance following completed treatment. Use additional code to identify any applicable history of disease code ( Z86 .-, Z87 .-)
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 ...
Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled ...
If this visit is accomplished, the practice may bill at the highest evaluation and management code level for a follow-up visit and it also receives a $150 bonus payment. This program, coupled with a telephone assessment performed by a case manager, has reduced 30-day hospital readmission rates from 14 percent to 6 percent. CareMore Health Plan ...
Z08 is a billable diagnosis code used to specify encntr for follow-up exam after trtmt for malignant neoplasm. View Z08 free coding rules and guidelines, index. ICD List 2023-2024 Edition. Search. Home; Codes. ICD-10-CM Codes; ... ICD-9-CM Code: V67.9 - Follow-up exam NOS Approximate Flag ...
Encounter for follow-up examination after completed treatment for malignant neoplasm Z08-Applicable To. Medical surveillance following completed treatment; ... For such conditions the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.
There are two ICD-10 codes for it: Z08 - Encounter for follow-up examination after completed treatment for malignant neoplasm. Z09 - Encounter for follow-up examination after treatment for conditions other than malignant neoplasm. These codes are meant to be used on patients who have either completed cancer treatment (Z08) or a non-cancer ...
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z09-Applicable To. Medical surveillance following completed treatment; ... For such conditions the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.
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 ...
In summary, aftercare codes refer to ongoing medical services provided to a patient after the active phase of treatment has ended, while follow-up codes refer to medical services provided to monitor a patient's condition or progress after a prior medical encounter. Tags: er follow up icd 10, icd 10 code for aftercare following orthopedic ...
Z51.89 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM Z51.89 became effective on October 1, 2023. This is the American ICD-10-CM version of Z51.89 - other international versions of ICD-10 Z51.89 may differ.
The appropriate codes for this scenario, according to this presentation, would be: ICD-10: Z47.1, Aftercare following surgery for joint replacement. ICD-10: Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant. ICD-10: R26.9 Abnormality, gait.
Effective Jan. 1, 2023, hospital observation codes 99217-99220 and 99224-99226 are deleted. These services are merged into the existing hospital inpatient services codes 99221-99223, 99231-99233, and 99238-99239, and the subsection is renamed Inpatient Hospital or Observation Care. As in the Office or Other Outpatient Services subsection, the ...
500 results found. Showing 1-25: ICD-10-CM Diagnosis Code Z39.2 [convert to ICD-9-CM] Encounter for routine postpartum follow - up. Routine follow up, postpartum (after childbirth); Routine postpartum follow up done. ICD-10-CM Diagnosis Code Z08 [convert to ICD-9-CM] Encounter for follow - up examination after completed treatment for malignant ...