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Oncology & Hematology Coding Alert

Reader Questions:

Follow This Guideline for Completed Treatment Follow-Ups

Question: When should I apply Z08 to a patient鈥檚 record, and how long after treatment should I use it?

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Answer: There is no timeframe attached to Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm). Instead, to apply the code correctly, you鈥檒l look to ICD-10-CM guideline I.C.21.c.8, which tells you the code should be used to 鈥渆xplain continuing surveillance following completed treatment of a disease, condition, or injury.鈥 So, the guideline continues, the code implies 鈥渢he condition has been fully treated and no longer exists.鈥

In other words, you鈥檒l use Z08 鈥渢o explain multiple visits鈥 when the condition has fully ended, the patient is no longer on a treatment plan or medication, and the provider is monitoring the patient to ensure the condition is, or continues to be, in remission.

Expert coding tip: If the conditions for using Z08 are met in the patient鈥檚 medical notes, the guideline tells you to use the code 鈥渋n conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.鈥 This is confirmed by the Use additional code instruction accompanying Z08, which tells you to use a code from Z85.- (Personal history of malignant neoplasm) in addition to the follow-up code.

But remember, the guideline also tells you that if a follow-up visit reveals the condition has recurred, 鈥渢hen the diagnosis code for the condition should be assigned in place of the follow-up code.鈥