2025 ICD-10-CM code Z45.4
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Encounters for other specific health care (Z40-Z53) Factors influencing health status and contact with health services (Z00-Z99) Feed
Encounter for adjustment and management of an implanted nervous system device.
Modifiers may be applicable depending on the specific procedure and circumstances of the encounter.Consult the appropriate modifier guidelines.
Medical necessity for this code would depend on the clinical indication for the adjustment or management of the implanted device.Documentation should clearly demonstrate the need for the procedure based on the patient's symptoms, diagnostic findings, and the expected benefit of the intervention.
The clinical responsibility for this code would typically fall on a neurosurgeon, neurologist, or other specialist managing the implanted nervous system device, depending on the specific device and patient condition.
- Factors influencing health status and contact with health services (Z00-Z99)
- Z45.4 is a child code under Z45 (Encounter for adjustment and management of implanted device).
In simple words: This code is used when someone goes to the doctor for a check-up or adjustment of a device that's already been implanted in their nervous system (like a spinal cord stimulator or shunt). It does not include visits due to problems with the device.
This code signifies an encounter for the adjustment and management of an implanted nervous system device.This includes procedures such as removal or replacement of the device.It excludes instances where the encounter is due to device malfunction or complications, which should be coded separately.It also excludes encounters for fitting and adjusting non-implanted devices.
Example 1: A patient with a cerebrospinal fluid shunt requiring adjustment of the shunt valve due to increased intracranial pressure., A patient with a deep brain stimulator (DBS) who needs a programming adjustment to optimize therapy., A patient who requires removal of an implanted spinal cord stimulator due to infection or device failure (Note:This requires additional coding for the infection or failure itself).
Detailed documentation should include the type of implanted nervous system device, reason for the encounter (adjustment, replacement, removal), procedure performed (if any), and the physician's assessment of the patient's response to the procedure or adjustment.Pre and post-operative assessments, imaging (as applicable), and device function data are also essential.
** This code is intended to capture the reason for the encounter.The specific procedures performed should be coded separately with appropriate CPT, HCPCS, or other relevant procedure codes.Always ensure proper documentation to support the medical necessity of the encounter.
- Payment Status: Active
- Modifier TC rule: Not applicable to this code.
- Specialties:Neurosurgery, Neurology
- Place of Service:Office, Hospital (Inpatient or Outpatient), Ambulatory Surgical Center