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Coding resolved conditions ALONG WITH current conditions

I know that follow-up visits for resolved conditions are to be coded with the follow-up code (typically Z09) and then the history code for the now-resolved condition.

My question is:

How do you code / sequence codes for a visit that includes BOTH resolved AND ongoing and/or chronic conditions?

Here are a few examples of what I mean, where I am unsure of how you would code / sequence these…


  1. Patient is seen for:
    B/l foot pain due to an injury
    Sleep disorder due to shift work

    The sleep disorder has resolved because the patient switched their shift at work, but the foot pain continues as the injury is still healing.

    ——————————

  2. Patient is seen for:
    URI

    All URI symptoms have resolved. Patient mentions dysuria and is given antibiotics for UTI.

    —————

  3. Patient is seen for:
    Final wound check from laceration
    Hypertension (already diagnosed – chronic)

    Wound is completely healed. Hypertension is stable.

I am not having any luck finding guidance on this, so I really appreciate any help you can give!! Thank you!!

Medical Billing and Coding Forum

Help with dx code for resolved symptoms

The patient was seen for a sore throat and painful swallowing but the documentation says that the symptoms had resolved. This is the first time the patient is being seen for this problem, but it is an established patient. Z09 seems inappropriate since this is not a follow up visit for the problem. What code should be used here?

Medical Billing and Coding Forum

Coding resolved conditions

Is it appropriate to code a resolved condition? Here’s the situation. Pt came in for follow-up of "condition". HPI says condition was present, treated, and now appears to be resolved. There are no findings on exam. Under the impression and plan it says Dx 1-"condition"; resolved. Return to clinic yearly or if condition recurs. The physician wants to assign the ICD-10 code for the condition that is not there anymore.

Medical Billing and Coding Forum