Coding for subsequent PET (Positron Emission Tomography) scans along with a history of the malignant neoplasm

Q.

When a patient comes in for a subsequent PET (Positron Emission Tomography) scan, if the history states that the patient has completed treatment and that the imaging is for surveillance, do we assign a diagnosis code such as Z08 and then the history of the cancer code? Or do we just code the history of the cancer code?

A.

You would assign ICD-10-CM code Z08 and then the appropriate history code. Notes with code Z08 say to “Use additional code to identify the personal history of malignant neoplasm (Z85.-).”  If the patient has fee-for-service-Medicare, it is best to get an ABN signed prior to the exam because surveillance is not covered. You would need to check the patient’s policy for other payers to see if they cover surveillance exams. The ICD-10-CM code and complete description are:

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm