ICD-10 Training Camp: Beware of Coding Changes Easily Missed in ICD-10-CM, Part II

Note: This is the second part of an article published in our Getting Paid newsletter last week.  You can read Part 1 now.

ICD-9-CM classification has “V” codes describing “aftercare” encounters and “V” codes describing “follow-up” encounters.  In ICD-10, the rules change when the encounter is for aftercare of an acute injury.  Follow-up (surveillance codes), also has a noted rule change in ICD-10.  In the ICD-10 classification, the “V” codes as we know them in ICD-9-CM are listed as “Z” codes in Chapter 21 of the new classification.  

In ICD-9 we would have used the “aftercare healing” codes for these encounters, but not in ICD-10.   ICD-10 gives instructions to not use the aftercare codes, but to use the acute injury code and in the 7th place, the D is placed to indicate ‘subsequent encounter.’  The guidelines state “The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).” “Extension D” subsequent encounter is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment. Examples:

S83.511D – “Sprain of anterior cruciate ligament of right knee, subsequent encounter” or,

S72.21XD, “Displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing.”

If the patient presents for aftercare of a surgical procedure, the appropriate “Z” code is assigned in ICD-10-CM.  For example, an encounter for aftercare following heart transplant would be code Z48.21.    Another example for aftercare is code Z48.01 Encounter for change or removal of surgical wound dressing.

Aftercare codes may also be listed in other chapters of ICD-10

Aftercare codes may also be listed in other chapters of ICD-10.  An example is treatment for a sequela of cerebral infarction, Chapter Nine: I69.351, “Sequela of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.”

Follow-up codes are used for conditions that have completed treatment or for cancer patients to monitor the recurrence of cancer after treatment has been completed.  These are surveillance encounters, no complaints, no symptoms, no treatment currently rendered.  Previous resolved conditions require monitoring to detect recurrences.  ICD-9-CM coding guidelines (V67 series) state that follow-up codes are listed first unless a condition has recurred on the follow-up visit, then the diagnosis code should be listed first in place of the follow-up code.

ICD-10-CM coding guidelines differ in that if a condition is found to have recurred on a follow-up visit, the follow-up code is still used as first-listed and the diagnosis code is listed second.  Personal history codes should be assigned as an additional code with follow-up examinations.  An example of a follow-up code in ICD-10 is as follows: Z08 “Encounter for follow-up examination after completed treatment for malignant neoplasm.”  Category code Z08 includes: medical surveillance following completed treatment.  ICD-10 also instructs the coder to: Use additional code to identify any acquired absence of organs (Z90.-); Use additional code to identify the personal history of malignant neoplasm (Z85.-).  Additional characters will be needed on category Z90 and Z85 to complete the code assignment.  Medical record documentation must be specific for accurate code assignment.

Code Z08 is a full code; it does not require additional characters.  There is an Excludes1 note under category Z08.  This note states that if the reason for the encounter is aftercare following medical care (Z43-Z49, Z51), you are not to assign code Z08.

Category code Z09 describes an Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.

The distinction between “aftercare” and “follow-up” care must be determined prior to code assignment.  Aftercare for acute injuries will be assigned a code from Chapter 19, ICD-10, with the appropriate “subsequent care” 7^th character extender.  Encounters for “follow-up” care or surgical aftercare will be assigned a code from Chapter 21 of the ICD-10 Tabular list.  Documentation in the medical record must be clear on the circumstance and intent of the visit.