2025 ICD-10-CM code Z45.81
(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 Chapter 21: Factors influencing health status and contact with health services Feed
Encounter for adjustment or removal of a breast implant.
Modifiers may be applicable depending on the specific circumstances of the procedure (e.g., location, anesthesia type). Consult official coding guidelines for appropriate modifier usage.
Medical necessity is established by the clinical indication for implant adjustment or removal, such as pain, infection, or rupture.Documentation supporting the medical need for the procedure is crucial for reimbursement.
The clinical responsibility lies with the physician or surgeon performing the procedure. This might involve a plastic surgeon, general surgeon, or another relevant specialist. The physician's duties include pre-operative assessment, surgical procedure (adjustment or removal of implant), post-operative care, and follow-up.
In simple words: This code is used when someone goes to the doctor to have a breast implant adjusted or removed. This could be because the implant needs replacing, or it's being removed altogether.It doesn't include cases where there are problems with the implant, or if the implant is being put in for the first time for cosmetic reasons.
This ICD-10-CM code signifies an encounter for the adjustment or removal of a breast implant.This includes encounters for elective implant exchange due to material or size differences, removal of tissue expanders with or without simultaneous insertion of a permanent implant.It excludes complications of breast implants (T85.4-), initial breast implant insertion for cosmetic augmentation (Z41.1), and breast reconstruction post-mastectomy (Z42.1).
Example 1: A patient presents for the removal of a breast implant due to capsular contracture., A patient undergoes an elective exchange of a breast implant for a larger size., A patient requires the removal of a tissue expander and immediate placement of a permanent breast implant.
Complete medical history, physical examination findings, imaging studies (if applicable, such as mammogram or ultrasound), operative report, pathology report (if applicable), and any post-operative notes.
** This code should only be used for encounters specifically focused on the adjustment or removal of breast implants.If other procedures are performed during the same encounter, those should be coded separately.
- Payment Status: Active
- Specialties:Plastic Surgery, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)