2025 ICD-10-CM code Z96.6
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status (Z77-Z99) Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) Feed
Presence of orthopedic joint implants.
The medical necessity for using Z96.6 is to accurately reflect the patient's health status and history, which is essential for appropriate care management, particularly regarding the affected joint. It's not intended for use when the implant itself is the primary reason for the encounter (e.g., for implant revision surgery).
Clinicians should use this code to document the presence of an orthopedic joint implant.It's crucial for informing ongoing care and decision-making regarding future interventions related to the implant or the affected joint. It’s also relevant for patient safety, such as during MRI scans. The code should be used regardless of whether the implant is causing any current issues.
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- Z96: Presence of other functional implants
In simple words: This code indicates that the patient has an artificial joint implant.
This code indicates the presence of an orthopedic joint implant in a patient.It is used to document the presence of the implant, not any complications or procedures related to it.It signifies a past surgical intervention and may influence current health status or future treatment options.It should be accompanied by a procedure code if a procedure related to the implant is performed.
Example 1: A patient with a history of hip replacement presents for a routine check-up. The code Z96.6 is used to document the presence of the hip implant, even if the patient is not experiencing any symptoms related to the implant., A patient with a knee implant presents with pain in the knee.While a code for the pain is used as the primary diagnosis, Z96.6 is used as a secondary diagnosis to indicate the presence of the implant, which could be a contributing factor to the pain., A patient with a shoulder implant is scheduled for an MRI of the spine.Z96.6 is used to alert the MRI technician to the presence of the implant, which may require adjustments to the imaging protocol.
Documentation should clearly state the type and location of the orthopedic joint implant.Operative notes from the implant surgery are ideal.If the type or location is unknown, the appropriate unspecified code (e.g., Z96.60) should be used.
** Excludes2: complications of internal prosthetic devices, implants and grafts (T82-T85) and fitting and adjustment of prosthetic and other devices (Z44-Z46).Code also any follow-up examination (Z08-Z09) if applicable.
- Specialties:Orthopedic Surgery, General Surgery, Internal Medicine, Family Medicine, any specialty providing care to patients with joint implants.
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office, Independent Clinic, Federally Qualified Health Center, Public Health Clinic, Rural Health Clinic,Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home