2025 ICD-10-CM code T85.4
Mechanical complication of breast prosthesis and implant.
Medical necessity for the treatment of a mechanical complication of a breast prosthesis or implant must be clearly established.The documentation should explicitly link the patient's symptoms and the identified mechanical complication to a demonstrable impairment in function or quality of life. The chosen treatment should be the least invasive and most cost-effective option that is likely to address the complication and alleviate the patient's symptoms.
Diagnosis and management of complications arising from breast prostheses or implants fall under the purview of plastic and reconstructive surgeons, or other specialists involved in breast surgery. They are responsible for diagnosing the complication, determining appropriate treatment strategies (which could range from conservative management to surgical intervention), and providing post-treatment care.
In simple words: This code indicates a mechanical problem with a breast implant, such as a rupture, leak, or shift in position.
Mechanical complication of breast prosthesis and implant. This code describes a mechanical problem or malfunction specifically related to a breast prosthesis or implant, such as a rupture, leak, displacement, or capsular contracture.
Example 1: A patient presents with pain and asymmetry in her breast following breast augmentation surgery. Upon examination, the surgeon discovers a rupture in the implant, requiring surgical removal and replacement., A patient with a history of breast reconstruction experiences increasing firmness and discomfort in the reconstructed breast.The diagnosis is capsular contracture, a tightening of the scar tissue around the implant, necessitating surgical intervention to release the capsule or replace the implant., During a routine mammogram, a patient's breast implant is found to be displaced from its original position.This displacement is causing noticeable asymmetry and discomfort. The patient undergoes a procedure to reposition the implant.
Documentation should include a detailed history of the breast implant procedure, including the type of implant used, the date of surgery, and any prior complications. Physical examination findings describing the nature of the complication (e.g., pain, asymmetry, palpable abnormality, presence of fluid collections) should be clearly documented.Imaging studies, such as mammograms, ultrasounds, or MRIs, that confirm the diagnosis of a mechanical complication should be included in the record. The chosen treatment strategy and the rationale for the selected approach should be documented, along with informed consent obtained from the patient.
- Specialties:Plastic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center