2025 ICD-10-CM code Z96.9
(Active) Effective Date: N/A Revision Date: N/A Deletion 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 Factors influencing health status and contact with health services Feed
Presence of a functional implant, unspecified.
The medical necessity for coding Z96.9 is established when the presence of the implant is clinically relevant to the patient's current condition or treatment. For example, if the patient is experiencing complications possibly related to the implant, or if the presence of the implant might influence treatment decisions, proper documentation supporting this is required.
Documentation of the presence of a functional implant, regardless of the specific type.This is often recorded as part of a comprehensive patient history or when the presence of the implant is relevant to the current medical encounter.
- Factors influencing health status and contact with health services
- Z96 (Presence of other functional implants)
In simple words: This code means the patient has an implant, but the doctor doesn't know or need to know exactly what kind of implant it is.
This code indicates the presence of a functional implant in the body, where the specific type of implant is not specified or known.It is used when a patient has an implant but the details are unavailable or not relevant to the current encounter.This code is part of a broader category encompassing various types of implants, and it is crucial to specify the type whenever possible for better clinical accuracy.
Example 1: A patient presents for an unrelated checkup, and during the history taking, the physician notes the presence of a pacemaker (the exact type is unknown). Z96.9 is used to document the presence of the implant., A patient undergoes surgery, and an existing, unspecified implant is noted in the operative report.Z96.9 is appended to the procedural codes to indicate the existence of the implant., A patient is admitted to the hospital for a condition unrelated to a previously implanted device.The presence of this unspecified device is documented with Z96.9.
The medical record should clearly document the presence of an implant. Although the specific type of implant does not need to be identified, a general description such as "cardiac implant" or "joint implant" is helpful for clarity.
** This code should be used cautiously, and only when absolutely necessary.Efforts should be made to identify and use a more specific Z96 code whenever the information is available.
- Payment Status: Active
- Specialties:Various specialties may use this code, depending on the type of implant present (e.g., cardiology, orthopedics, ophthalmology).
- Place of Service:Office, Hospital (inpatient or outpatient), Skilled Nursing Facility, other