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Patricia Posted 1 Year(s) ago
Our patient came in as a new patient, with a history of testicular CA. in 2004, he had orchiectomy and radiation as treatment. Now he comes to us to follow up, no complaints, just labs done to ascertain status of CA. I am having trouble with a primary code.
SuperCoder Posted 1 Year(s) ago

Hi,

 

As per coding guidelines, appropriate ICD 10 codes for the mentioned scenario would be Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm), Z85.47 (Personal history of malignant neoplasm of testis) , Z90.79 (Acquired absence of other genital organ(s)).

 

 

Thank you!

Patricia Posted 1 Year(s) ago
Thank you, I appreciate your answer. However, those codes are labeled as non primary only.
SuperCoder Posted 1 Year(s) ago

Hi,

 

Per the ICD‐10‐CM guidelines “Do not code conditions that were previously treated and no longer exist.” “The follow‐up code (Z08) would be used to explain continuing surveillance following completed treatment of a disease, condition, or injury. It implies that the condition has been fully treated and no longer exists. Follow‐up codes may be used in 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. So in your mentioned scenario, patient had testicular CA in 2004. You have them return after the treatment was completed. Everything is resolved. Therefore your ICD‐10‐CM codes are Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm) and if you choose to also code the personal history, report Z85.47 (Personal history of malignant neoplasm of testis), Z90.79 (Acquired absence of other genital organ(s)) as a secondary codes.

 

 

Thank you!

Posted by Patricia, 1 Year(s). There are 4 posts. The latest reply is from SuperCoder.

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