2025 ICD-10-CM code Z85
Personal history of malignant neoplasm. Code first any follow-up examination after treatment of malignant neoplasm (Z08).
Medical necessity for using this code is established by the patient's history of malignancy and the need for ongoing surveillance or follow-up care to ensure early detection of recurrence or management of long-term effects of treatment.
The physician is responsible for accurately documenting the patient's history of malignancy and ensuring there is no current evidence of the disease before using this code.Follow-up care and surveillance are key aspects of clinical responsibility in these cases.
In simple words: The patient has a history of cancer but is not currently undergoing treatment and shows no signs of the disease. This code is used for check-ups after cancer treatment is complete.
Personal history of malignant neoplasm. This code indicates that the patient has a history of malignant neoplasm (cancer) but is currently not receiving treatment and there is no evidence of the disease.It is used for follow-up examinations after treatment has ended.Additional codes should be used to identify specific details like alcohol use, tobacco use or exposure, and occupational hazards.
Example 1: A patient who completed treatment for breast cancer two years ago and is currently disease-free presents for a routine follow-up. The appropriate code is Z85., A patient with a history of colon cancer, now in remission, is seen for an annual physical exam. Code Z85 is used to indicate their cancer history., A patient successfully treated for leukemia five years prior presents for a routine check-up with no signs of recurrence.Z85 is the correct code to reflect their history of malignancy.
Documentation should clearly state the type of cancer, the date of diagnosis, the date of completion of treatment, and confirmation of the absence of current disease.Any ongoing surveillance or monitoring should also be documented.
** It is important to code the follow up or surveillance visit as per guidelines, for example (Z08-Z09) alongside Z85.
- Specialties:Oncology, primary care, any specialty involved in long-term follow-up of cancer patients.
- Place of Service:Office, Outpatient Hospital, Clinic