A patient that had colonoscopy a few months ago with polypectomy, for adenomatous polyp, returns for follow-up examination to look for recurrence would be coded as a follow-up examination with Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.
Read and be guided by all the information within the medical record.įollow-up examination is typically performed when a patient has been found on previous exam to have a potentially malignant neoplasm or lesion that is suspicious for malignant transformation. However, the coder must be cautious as sometimes the physician will document “surveillance” colonoscopy when in fact what he is performing is a follow-up colonoscopy. Surveillance colonoscopies are still screenings. If a patient has had previous removal of colon polyps a few years ago and is now presenting for surveillance colonoscopy to look for any additional polyps or recurrence of the polyp this is coded with Z12.11, Encounter for screening for malignant neoplasm of colon as the first listed code. Surveillance is often used to describe the visit for the colonoscopy.
#Follow up icd 10 code#
When a screening colonoscopy is performed, the screening code would be reported regardless of the findings during the exam or other procedures performed due to the findings. The coder should also report the polyp or findings as additional diagnosis codes. If the patient presents for a screening colonoscopy and a polyp or any other lesion/diagnosis is found, the primary diagnosis is still going to be Z12.11, Encounter for screening for malignant neoplasm of colon. follow-up did not change with the implementation of ICD-10-CM. The coding advice for reporting screening vs. All colonoscopy procedures are performed to look for potential malignancy and some coders think that all of these should be coded as screenings, code Z12.11. Coding colonoscopy records has always been a challenge when it comes to reporting the primary diagnosis for the account.
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