Z09 vs Z42
Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) compared with Z42 (Encounter for plastic and reconstructive surgery following medical procedure or healed injury), from the official CMS tabular data. Both may be reported when both conditions are documented (Excludes2).
Can these codes be reported together?
Yes, when both are documented. Z42 carries an Excludes2 note covering Z09: “follow-up examination for medical surveillance after treatment (Z08-Z09)”
Excludes2 marks distinct conditions — both may be reported when both are documented.
Side by side
| Z09Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm | Z42Encounter for plastic and reconstructive surgery following medical procedure or healed injury | |
|---|---|---|
| Billing status | Billable | Non-billable header |
| Classification | Z00-Z99 — Factors Influencing Health Status and Contact with Health Services (Z00-Z99) | Z00-Z99 — Factors Influencing Health Status and Contact with Health Services (Z00-Z99) |
| Definition | Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm is a billable ICD-10-CM diagnosis code (Z09). | Encounter for plastic and reconstructive surgery following medical procedure or healed injury is a non-billable ICD-10-CM category code (Z42). |
| Includes | Medical surveillance following completed treatment | — |
| Use additional code | code to identify any applicable history of disease code (Z86.-, Z87.-) | — |
Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources