Follow-Up After Completed Treatment ICD-10-CM codes

Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) and Z08 (the same after completed treatment for malignant neoplasm) describe surveillance visits for a condition that has been fully treated and no longer exists. The guidelines (section I.C.21.c.8) say the follow-up code is sequenced first, followed by the appropriate history code: Z09 with Z87.440 for a check after a resolved UTI, Z09 with Z87.81 after a healed fracture, Z08 with Z85.3 for the oncology surveillance visit after breast cancer treatment.

If the condition is found to have recurred at the follow-up visit, drop the follow-up code and report the condition itself. A follow-up visit that finds a new problem takes the problem as the first-listed diagnosis. Z08 is also the code for surveillance imaging and tumor markers in a cancer survivor; an elevated result such as R97.21 (rising PSA after prostate cancer treatment) is added as a secondary code and moves the patient out of Z08 territory once recurrence is confirmed.

Follow-up codes are not aftercare codes. A patient still healing from surgery is under Z47 or Z48 aftercare, a healing fracture uses the injury code with 7th character D, and a patient still receiving chemotherapy or hormonal therapy has an active cancer code, not Z08. Z09 and Z08 only apply once treatment is finished, so a post-op visit inside the global period or a wound check is not Z09.

Z92.21 (personal history of antineoplastic chemotherapy) and Z92.3 (personal history of irradiation) can be added to Z08 to document what treatment was completed, and they support surveillance for late effects. Z86.73 (history of TIA or stroke without residual deficits) and Z86.718 (history of DVT) are typical partners for Z09 when the follow-up is for a resolved vascular event no longer under active treatment.