Z09 vs Z53
Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) compared with Z53 (Persons encountering health services for specific procedures and treatment, not carried out), 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. Z53 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 | Z53Persons encountering health services for specific procedures and treatment, not carried out | |
|---|---|---|
| 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). | Persons encountering health services for specific procedures and treatment, not carried out is a non-billable ICD-10-CM category code (Z53). |
| 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