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DX code Z48.815

Heidi Posted Tue 28th of August, 2018 08:10:32 AM
DX code Z48.815 (Encounter for surgical aftercare following surgery on the digestive system); do you think this is a DX code that can be used on follow up office visits after an EGD/Colonoscopy/ERCP? I want to make sure it doesn't have to necesarrily be an actual surgery that Rectal Surgeons would perform on patients; if a patient had a Colonoscopy due to Constipation, is it ok to bill that office visit with K59.00 and Z48.815 for documenting purposes? Thanks for your assistance on this! :)
SuperCoder Answered Wed 29th of August, 2018 03:19:46 AM

Hi Sherry,

Thank you for your Question.

ICD 10 CM Z48.815 (Encounter for surgical aftercare following surgery on the digestive system) is used  for postprocedural aftercare  when care required following a procedure or during the healing or recovery phase or for long-term medical care for circumstances related to the procedure.

A follow-up examination can be coded with Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm when patient is coming after completion of treatment.

if a patient had a Colonoscopy due to Constipation in this scenario You can bill constipation as a primary diagnosis and if the documentation states physician had provided some care in regards to the colonoscopy or other surgical intervention performed then ICD 10 CM Z48.815 may be reported.

Note: If the colonoscopy report states some more definitive diagnosis over constipation bill that diagnosis as primary diagnosis.

Hope this Helps!

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