FY2027
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Excludes1 pair

Z09 vs Z48-

Z09 and Z48 are not coded together. ICD-10-CM declares them mutually exclusive with an Excludes1 note — the two conditions are not expected to occur together, so exactly one of them is normally correct for a given encounter. The Official Guidelines carve out one exception: if the two conditions are clearly unrelated to each other, both may be reported.

The official note, declared on Z48
encounter for follow-up examination after completed treatment (Z08-Z09)
Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Billable
Chapter 21
Factors influencing health status and contact with health services
Section
Z00-Z13
Use when the record says
  • Medical surveillance following completed treatment
Indexed under
  • Admission › follow-up examination
  • Examination › follow-up (routine) (following)
  • Examination › following › treatment (for)
  • Examination › follow-up › chemotherapy NEC
  • Examination › follow-up › fracture
Z48

Encounter for other postprocedural aftercare

Not billable
Chapter 21
Factors influencing health status and contact with health services
Section
Z40-Z53

Excludes1 is not always absolute: where two conditions covered by the note are genuinely unrelated, CMS guidance permits reporting both. Document the reasoning rather than assuming it. More on Excludes1 vs Excludes2 · FY2027