2025 ICD-10-CM code Z96.61
(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 Chapter 21: Factors influencing health status and contact with health services Feed
Presence of an artificial shoulder joint.
Modifiers may be applicable depending on the context (e.g., laterality modifiers, if the specific codes Z96.611, Z96.612, or Z96.619 are used). Consult current coding guidelines for details on appropriate modifier use.
Medical necessity for coding Z96.61 depends on the clinical context. For example, documentation supporting the medical necessity of a routine follow-up visit would be a physician's order or note indicating the need for assessment.For revision surgeries, the documentation must support the medical necessity of the procedure due to complications or implant failure.
The clinical responsibility for this code depends on the context. It could involve the orthopedist who performed the surgery, the primary care physician managing post-operative care, or another specialist depending on the reason for the encounter. This code itself does not specify clinical responsibilities.
- Chapter 21: Factors influencing health status and contact with health services
- Z96.6 Presence of orthopedic joint implants
In simple words: This code means a person has a replacement shoulder joint.
This code indicates the presence of an artificial shoulder joint, regardless of the reason for the encounter.It is used to document the existence of the implant and may be used in conjunction with other codes to describe the reason for the visit, such as a follow-up examination or treatment related to the implant.
Example 1: A patient presents for a routine follow-up appointment after shoulder replacement surgery. The physician reviews the patient's progress, assesses range of motion and function, and orders any necessary imaging studies.Code Z96.61 is used to document the presence of the implant., A patient presents to the emergency department with shoulder pain after a fall. Imaging reveals no fracture, but the presence of the artificial shoulder joint is noted. Code Z96.61 is documented along with the appropriate codes for shoulder pain and the fall (if applicable)., A patient requires a revision surgery on their existing artificial shoulder joint.Code Z96.61 is used along with procedure codes that describe the surgical procedures performed.
Documentation should include details regarding the type of artificial shoulder joint, date of implantation, and any complications or related conditions.For follow-up appointments, notes should indicate the assessment of the implant, range of motion, pain levels, and functional status.For surgical procedures, operative reports should provide details of the procedure performed.
** This code should only be used when the presence of the artificial shoulder joint is relevant to the encounter. It is not meant to replace codes that describe the reason for the visit.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Orthopedic Surgery, Rheumatology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center, other