2025 ICD-10-CM code Z95.811
(Active) Effective Date: N/A Revision 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 Chapter 21: Factors influencing health status and contact with health services Feed
Presence of a heart assist device.
The medical necessity for coding Z95.811 lies in the impact of the heart assist device on the patient's care. The presence of the device will directly affect the care provided, the type and frequency of follow-up, and the overall clinical management plan.The medical necessity is established by the provider's documentation showing the device's impact on the care during the encounter.
The clinical responsibility associated with this code would depend on the context. It might involve cardiologists, cardiac surgeons, or other specialists involved in the patient's care related to the heart assist device. The physician's duties may include monitoring the device's function, managing complications, and providing ongoing care.
- Chapter 21: Factors influencing health status and contact with health services
- Z95.811 falls under the broader category of Z95 (Presence of cardiac and vascular implants and grafts) and the even broader chapter of Z codes (Factors influencing health status and contact with health services).
In simple words: This code means the patient has a heart assist device implanted.Doctors use this code when the device affects the patient's treatment during their visit, not as the main reason for the visit.
This code signifies the presence of a heart assist device in a patient.It's used as an additional code when the device's presence impacts the patient's care during a specific healthcare encounter. This code does not represent the primary diagnosis or reason for visit; rather, it indicates a relevant co-morbidity or condition influencing the patient's care.A corresponding procedure code should be included if any procedure was performed related to the device.
Example 1: A patient with chronic heart failure is admitted for routine monitoring of their implanted left ventricular assist device (LVAD).The LVAD is functioning well, but the patient requires adjustments to their anticoagulation therapy. Z95.811 is coded in addition to the codes for the heart failure and the anticoagulation therapy management., A patient with a newly implanted LVAD is admitted for management of a suspected infection around the device site.Z95.811 is coded along with codes for the infection, imaging studies (if performed), and any surgical procedures (if performed) to address the infection., A patient with an LVAD requires a scheduled outpatient visit for device maintenance, including checks of its function and battery life, along with adjustments to their medications. Z95.811 is coded as an additional code reflecting the presence and management of the LVAD.
Complete medical history, including details of the heart assist device (type, model, date of implantation); device function reports (if available); medication records; results of any diagnostic tests (e.g., blood work, echocardiogram); clinical notes reflecting the patient's overall clinical picture and how the presence of the device influences their care during the encounter.
** Always ensure accurate documentation of the device's type and function, as well as its impact on the patient's treatment plan.Proper documentation is crucial for appropriate coding and reimbursement.
- Payment Status: Active
- Specialties:Cardiology, Cardiac Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Ambulatory Surgical Center