2025 ICD-10-CM code Z42.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Encounter - Encounters for other specific health care Chapter 21: Factors influencing health status and contact with health services Feed
Encounter for breast reconstruction following mastectomy.
Modifiers may be applicable depending on the specific circumstances of the service provided (e.g., anesthesia, assistant surgeon).
Medical necessity for breast reconstruction following mastectomy is typically established through the patient's history of mastectomy due to cancer, trauma, or other medical conditions.It might also be supported by documentation demonstrating the impact of the mastectomy on the patient's physical or psychological well-being, justifying the need for reconstruction.
The clinical responsibility includes the surgical procedure itself, pre-operative assessment, post-operative care, and follow-up appointments.The surgeon's duties involve planning and executing the reconstruction, managing any complications, and monitoring patient recovery.
- Chapter 21: Factors influencing health status and contact with health services
- Z40-Z53 (Encounters for other specific health care)
In simple words: This code is used when someone goes to the doctor for a breast reconstruction surgery after having a mastectomy (removal of a breast).
This ICD-10-CM code signifies an encounter for breast reconstruction surgery that takes place after a mastectomy.It indicates the reason for the visit and should be used when the patient is receiving care specifically for the breast reconstruction, not for other related conditions.
Example 1: A patient undergoes a mastectomy due to breast cancer.Following successful cancer treatment and healing, she schedules a consultation and surgery for breast reconstruction. Code Z42.1 would be used to represent this encounter., A patient has a mastectomy due to a traumatic injury.After the initial healing, she is seen for breast reconstruction to restore symmetry and improve body image. Code Z42.1 accurately captures this visit., A patient has had a prior mastectomy and seeks revision surgery to improve the aesthetic outcome of her breast reconstruction. Code Z42.1 would be used for this follow-up reconstructive surgery.
Detailed operative notes describing the procedure performed, including implants used if applicable.Pre-operative imaging (if any), pathology reports from the mastectomy (if relevant to the reconstruction), and post-operative assessments are crucial for accurate coding.
** Ensure proper documentation to support the medical necessity of the breast reconstruction.The code should only be used when the primary reason for the encounter is the breast reconstruction procedure itself. This is not a stand alone code and must be used with a procedural code.
- Payment Status: Active
- Modifier TC rule: Not applicable to this diagnostic code.
- Fee Schedule: Information on historical fee schedules would depend on the payer and the year of service; consult relevant fee schedules for this data.
- Specialties:Surgical Oncology, Plastic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Inpatient Hospital