ICD-10-CM Code Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Version 2020 Billable Code Unacceptable Principal Diagnosis POA Exempt

Valid for Submission

Z09 is a billable code used to specify a medical diagnosis of encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code Z09 might also be used to specify conditions or terms like attends hypertension monitoring, chiropody follow-up, chronic disease - follow-up assessment, follow-up , follow-up 1 day, follow-up 1 month, etc The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

The code Z09 describes a circumstance which influences the patient's health status but not a current illness or injury. The code is unacceptable as a principal diagnosis.

ICD-10:Z09
Short Description:Encntr for f/u exam aft trtmt for cond oth than malig neoplm
Long Description:Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code Z09:

Inclusion Terms

Inclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
  • Medical surveillance following completed treatment

Use Additional Code

Use Additional Code
The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.
  • code to identify any applicable history of disease code Z86 Z87

Type 1 Excludes

Type 1 Excludes
A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
  • aftercare following medical care Z43 Z49 Z51
  • surveillance of contraception Z30.4
  • surveillance of prosthetic and other medical devices Z44 Z46

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code Z09 are found in the index:


Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10 Code Edits are applicable to this code:

  • Unacceptable principal diagnosis - There are selected codes that describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause. These codes are considered unacceptable as a principal diagnosis.

Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Attends hypertension monitoring
  • Chiropody follow-up
  • Chronic disease - follow-up assessment
  • Follow-up
  • Follow-up 1 day
  • Follow-up 1 month
  • Follow-up 1 week
  • Follow-up 1 year
  • Follow-up 2 weeks
  • Follow-up 2-3 days
  • Follow-up 2-3 months
  • Follow-up 3 weeks
  • Follow-up 4-6 days
  • Follow-up 4-6 months
  • Follow-up 6 months
  • Follow-up 6 weeks
  • Follow-up 7-11 months
  • Follow-up in outpatient clinic
  • Follow-up orthopedic assessment
  • Fracture therapy follow-up
  • Heart failure follow-up
  • High risk implant follow-up
  • Hypertension monitoring check done
  • Hypertension monitoring status
  • Hypertension monitoring status
  • Hypertension:follow-up default
  • Post-discharge follow-up
  • Postoperative visit
  • Radiotherapy follow-up
  • Retinopathy follow up
  • Seen in hypertension clinic
  • Surgical follow-up
  • Surgical follow-up - normal
  • Transplant follow-up
  • Under follow-up

Present on Admission (POA)

Z09 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here .

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert Z09 to ICD-9

  • V67.00 - Follow-up surgery NOS (Approximate Flag)
  • V67.09 - Follow-up surgery NEC (Approximate Flag)
  • V67.1 - Radiotherapy follow-up (Approximate Flag)
  • V67.2 - Chemotherapy follow-up (Approximate Flag)
  • V67.3 - Psychiatric follow-up (Approximate Flag)
  • V67.4 - FU exam treatd healed fx (Approximate Flag)
  • V67.51 - High-risk rx NEC exam (Approximate Flag)
  • V67.59 - Follow-up exam NEC (Approximate Flag)
  • V67.6 - Comb treatment follow-up (Approximate Flag)
  • V67.9 - Follow-up exam NOS (Approximate Flag)

Code Classification

  • Factors influencing health status and contact with health services (Z00–Z99)
    • Persons encountering health services for examinations (Z00-Z13)
      • Encntr for f/u exam aft trtmt for cond oth than malig neoplm (Z09)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (First year ICD-10-CM implemented into the HIPAA code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020