2025 ICD-10-CM code Z96.612
(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 a left artificial shoulder joint.
The presence of a left artificial shoulder joint is not a condition requiring treatment; this code is used for documentation of the finding and is relevant for clinical management and decision-making, particularly in the context of other diagnoses or procedures. It is medically necessary to document this in the patient's medical record.
Documentation of the presence of the left artificial shoulder joint. This is typically part of a comprehensive patient history and physical examination, or it may be relevant in the context of follow-up care related to the prosthetic joint.
- Chapter 21: Factors influencing health status and contact with health services
- Z96.61 (Presence of artificial shoulder joint)
In simple words: This code means the patient has a replacement left shoulder joint.
This code indicates the presence of an artificial left shoulder joint.It is used to document the existence of a prosthetic shoulder joint in the patient's left shoulder, irrespective of the reason for the encounter.This code is not used to indicate complications or procedures related to the artificial joint.
Example 1: A patient presents for a routine check-up after a left total shoulder arthroplasty. The physician documents Z96.612 to reflect the presence of the artificial joint., A patient is involved in an accident and sustains injuries to the left upper extremity.The presence of the left artificial shoulder joint (Z96.612) is documented to inform treatment decisions.Additional codes would be used to document the nature of the injuries., A patient presents to the emergency room with left shoulder pain.The physician's examination reveals an existing artificial shoulder joint. The code Z96.612 is used to document this finding alongside other codes to clarify the nature of the pain and any associated issues.
A complete history and physical examination should be documented, including details of the patient's previous shoulder surgery (date, type of surgery, any complications), current symptoms, and the functional status of the left shoulder. Imaging studies, if performed, should be included.
** This code is typically used as a secondary diagnosis code in conjunction with other codes describing the primary reason for the encounter.The presence of this artificial joint may influence treatment decisions or the management of other conditions.
- Payment Status: Active
- Specialties:Orthopedics, Rheumatology, General Surgery
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Emergency Room - Hospital