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Difference between Aftercare and Followup ICD 10 codes

Being a Medical coder, we always face new challenges in coding ICD 10 codes. In ICD 9 diagnosis codes, we were not so much confused because of limited number of codes. For example, earlier we used to code only one code for pregnancy complication irrespective of first, second or third trimester, but ICD 10 we have specific ICD 10 codes for each trimester for same condition in ICD 9.

Initially, we all have done coding errors in ICD 10, but we should learn from all these errors. Once you improve in diagnosis coding, you will automatically see an improvement in your coding skills. Still I see many coders struggle to use the status Z codes.

And even if they found the correct Z code, then they have a doubt in using it primary or secondary diagnosis.  If you know the ICD 10 coding guidelines, you can code  80% of correct diagnosis. Today will try to learn more about ICD 10 codes for followup and aftercare diagnosis.

Difference between Aftercare and Followup ICD 10 codes

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Aftercare ICD 10 codes

Aftercare codes are used only when the condition is under treatment or under healing phase after initial visit or treatment. Aftercare Z codes should not be reported when the treatment is for current or acute disease. Few exception are their,  aftercare Z codes should not be reported for aftercare for injuries. Now, in ICD 10 we have intial, subsequent or sequela encounter codes for injury. Hence, for coding healing phase of injury codes, we can directly choose the 7th character for routine or delay healing of injuries for subsequent encounter as primary diagnosis without use of any aftercare Z codes. 

Aftercare ICD 10 codes are coded as primary or first listed diagnosis only. We can use multiple ICD 10 encounter codes  together when more than one services are provided. For example, when a patient receive both the chemotherapy  and radiotherapy as antineoplastic therapy, in such scenario we can code both the encounters together. The encounter codes can be sequenced primary depending on the physician’s documentation in the medical record.

Z51.0 Encounter for antineoplastic radiation therapy

Z51.1 Encounter for antineoplastic chemotherapy and immunotherapy

Below are few examples of Aftercare ICD 10 Z codes.

Z48.81 Encounter for surgical aftercare following surgery on specified body systems

Z48.810 Encounter for surgical aftercare following surgery on the sense organs

Z48.811 Encounter for surgical aftercare following surgery on the nervous system

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Z48.812 Encounter for surgical aftercare following surgery on the circulatory system

Z48.813 Encounter for surgical aftercare following surgery on the respiratory system

Z48.814 Encounter for surgical aftercare following surgery on the teeth or oral cavity

Z48.815 Encounter for surgical aftercare following surgery on the digestive system

Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system

Do remember these Z codes have to be used as first listed or primary diagnosis. We have a separate list of status Z codes which needs to be used secondary diagnosis only.

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Followup ICD 10 codes

Followup ICD 10 codes are used very frequently. Medical coders are really confused while using these ICD 10 codes. Many coders still don’t know the difference between Aftercare and Followup ICD 10 codes. Followup ICD 10 codes are used only for visits, when the condition is totally treated , resolved or healed (fracture). For example, Z09 ICD 10 code is a Follow-up examination after treatment for conditions other than malignant neoplasm, and reported only when the neoplasm is fully treated and the patient comes for a followup visit. Here, we code Z09 as primary diagnosis and history of malignant neoplasm as secondary diagnosis. 

Below is the list of few examples of Followup ICD 10 Z codes.

Z09 Follow-up examination after treatment for conditions other than malignant neoplasm

Z09.0 Malignant neoplasms follow-up examination after surgery for other conditions

Z09.1 Follow-up examination after radiotherapy for other conditions

Z09.2 Follow-up examination after chemotherapy for other conditions

Z09.3 Follow-up examination after psychotherapy

Z09.4 Follow-up examination after treatment of fracture

Z09.7 Follow-up examination after combined treatment for other conditions

Z09.8 Follow-up examination after other treatment for other conditions

Z09.9 Follow-up examination after unspecified treatment for other conditions

 If you know when to use the followup and aftercare codes, you will easily become perfect in using Z codes. The more you use these codes, the more you will become familiar with them. Do follow all the coding guidelines with ICD 10 codes, such techniques will help you to become a perfect ICD 10 coder.

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