how do i code a hospital follow up at a pediatric office for icd-10

by Coby Stracke 6 min read

Answer: There is not such a code in ICD-10, and you are correct in selecting Z09 as the most accurate code for this service, says Donelle Holle, RN, practice administrator with Fort Wayne Pediatrics and President of Peds Coding, Inc.

Full Answer

What is the ICD 10 code for follow-up examination?

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm. Z09 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM Z09 became effective on October 1, 2019.

What is the ICD 10 code for routine child health examination?

Diagnosis code Z00.121 (encounter for routine child health examination with abnormal findings) and the appropriate problem diagnosis would be used. If a nurse visit is provided (e.g., weight screen only), code 99211 may be reported.

What is the follow-up code for multiple visits?

A follow-up code may be used to explain multiple visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code. Hope this helps! You must log in or register to reply here.

What is the CPT code for inpatient care of a newborn?

CPT 99477 For the initiation of inpatient care of the normal newborn report 99460 For initiation of the care of the critically ill neonate use 99468 For initiation of inpatient hospital care for the neonate not requiring intensive observation, frequent interventions or other intensive care services use 99221-99223

How do you code a hospital follow up?

Follow-up visits, like initial visits, should be coded using the appropriate evaluation and management (E/M) code (i.e., 99211–99215). Given the limited interaction with the patient and limited work involved, the level of service is likely to be low (e.g., 99211 or 99212).

What is the ICD-10 code for hospital follow up?

Z09 - Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm | ICD-10-CM.

How do you code pediatric visits?

Example: A child has a well-child visit EPSDT (99381 – 99461), with a well child diagnosis code (Z-code) in the first position; the sick visit code (99211 – 99215) with the modifier 25 and with the illness diagnosis CPT code in the second position.

When a diagnosis is not established at the first visit and follow up visits are required before determining a primary diagnosis What should the coder do?

When a diagnosis is not established at the first visit and follow-up visits are required before determining a primary diagnosis, what should the coder do? Code the signs and symptoms. (Instead of inconclusive diagnoses, the specific signs and symptoms are coded and reported.)

What is the difference between follow up and aftercare?

Follow-up. The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.

When should aftercare codes be used?

Aftercare visit codes are assigned in situations in which the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.

What is the CPT code for pediatric visit?

For established patients making a well baby/well child care visits: • For infants under age 1, use CPT code 99391. For children ages 1 to 4 (early childhood), use CPT code 99392. For children ages 5 to 11 (late childhood), use CPT code 99393.

Can 99393 and 99173 be billed together?

Visual acuity testing (99173) is a covered, separately reimbursable service when performed in conjunction with a preventive medicine service code (99382, 99383, 99392, 99393) for patients aged 3-5 years.

What is the code 99213?

CPT® code 99213: Established patient office visit, 20-29 minutes | American Medical Association.

What is the difference between subsequent encounter and sequelae?

D (subsequent encounter) describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery. S (sequela) indicates a complication or condition that arises as a direct result of an injury.

What is the difference between initial encounter and subsequent encounter?

As Rhonda Buckholtz, AAPC Vice President of Strategic Development, explains, “When the doctor sees the patient and develops his plan of care—that is active treatment. When the patient is following the plan—that is subsequent.

Can ICD 10 code be primary Z09?

Z09 ICD 10 codes should be used for diseases or disroder other than malignant neoplasm which has been completed treatment. For example, any history of disease should be coded with Z08 ICD 10 code as primary followed by the history of disease code.

When should aftercare Z codes not be used?

The aftercare Z code should not be used if treatment is directed at a current, acute disease.

What is aftercare code?

Aftercare and Follow-up: ICD-10 Coding 1 The aftercare Z code should not be used if treatment is directed at a current, acute disease. 2 The aftercare Z codes should also not be used for aftercare for injuries.

Care of the Normal Newborn Infant

Evaluation and management (E/M) services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include:

Newborn Care in the Office

After the newborn has been discharged to home, it is common practice to see the infant to assess for jaundice or any feeding problems. Coding for this service depends on the provider of the service and whether the visit is in follow-up to an already identified problem or screening for problems.


Family physicians who perform newborn circumcision should separately report this service. Codes for circumcision procedures include:

Caring for Sick Newborns

When providing E/M services to other than normal newborns, choose the level of care based on the intensity of the service and status of the newborn. Care of newborns who are not normal but do not require intensive services may be reported with codes for initial hospital care (99221-99223).

Newborn Critical Care

When the newborn is critically ill or injured, codes exist for reporting of services provided during interfacility transport, initial critical care, and subsequent critical services.

Critical Care During Transport

Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24-months of age or less, are reported based on the time of face-to-face care beginning when the physician assumes primary responsibility at the referring hospital/facility and ending when the receiving hospital/facility accepts responsibility for the patient's care.

Inpatient Neonatal Critical Care

The initial day of critical care for the evaluation and management of a critically ill neonate, 28-days of age or less, is reported with code 99468. Only one physician may report this code.

What is the CPT code for transitional care management?

The CPT® guidelines for transitional care management (TCM) codes 99495 and 99496 seem straightforward, initially, but the details are trickier than is commonly recognized. Here’s what you need to know to report these services appropriately.

How long does a TCM provider have to bill for E/M?

Although TCM codes require continuous provider access from the moment of discharge through 29 days post discharge, the provider may bill separately for additional evaluation and management (E/M) services provided within the month if performed on a date after the initial face-to-face visit.

How to communicate post discharge?

Communication within the first two business days post discharge can be performed by the physician or other qualified health professional and/or licensed clinical staff under the physician’s direction. Communication may be with direct contact (face-to-face), via telephone, or by electronic send/receive messaging .#N#Documentation of this communication should extend beyond “patient OK.” Post discharge communication may assess and support treatment regimen adherence and medication management. Communication can also facilitate access to care and service needed by the patient and family. If the physician or other qualified professional is not directly involved in this communication, documentation of the conversation must be shared with the provider to address the status of the patient and the need for follow-up on any pending diagnostic tests or treatments.#N#Communication regarding care within the two-day window may be engaged with the patient, and/or family member, guardian, caretaker, surrogate decision maker, or other professional. This communication gives opportunity to educate the patient and family members and clarify post-discharge instructions.

What is the TCM number for medication management?

Medication therapy management services (99487-99489) Medication management therapy services (99605-99607) Lastly, if a provider performs a procedure with a global period, then the same provider may not bill TCM services during the global period.