Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm (Z09)
The ICD-10 code Z09 is used to document an encounter for follow-up examination after completed treatment for conditions other than malignant neoplasms. It applies when a patient returns for monitoring or assessment following recovery or stabilization of a health issue that is not cancer.
This code covers a wide range of follow-up scenarios, including common situations such as chronic disease follow-up assessments, hypertension monitoring, and various postoperative or specialized follow-ups like surgical, orthopedic, transplant, or radiotherapy follow-ups. Synonyms like “hypertension monitoring check done,” “post-discharge follow-up,” and “fracture therapy follow-up” help clarify that Z09 is the correct code when documenting routine visits meant to check a patient's progress after active treatment has ended for non-cancer conditions. Understanding the use of the ICD-10 code for follow-up care ensures accurate coding for outpatient or clinic visits focused on ongoing health maintenance rather than acute treatment.
Factors influencing health status and contact with health services (Z00–Z99)
Persons encountering health services for examinations (Z00-Z13)
- Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm (Z09)
Instructional Notations
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
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.
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.
