Z45.81
Encounter for adjustment or removal of breast implant
Z45.81 is a non-billable ICD-10-CM code header for encounter for adjustment or removal of breast implant. Report a more specific code from it instead. It is part of the FY2027 code set, effective October 1, 2026. The more specific codes under it are Z45.811 Encounter for adjustment or removal of right breast implant, Z45.812 Encounter for adjustment or removal of left breast implant and Z45.819 Encounter for adjustment or removal of unspecified breast implant. Its coding notes include 4 Excludes1 entries and 2 Excludes2 entries.
Guidelines tip
From the FY2027 Official Guidelines. ICD10Ref adds no rules of its own.
Aftercare Z codes are not used when treatment is directed at a current, acute disease, or for aftercare of an injury. For an injury, the acute injury code with a 7th character for a subsequent encounter is used.
Excludes1
Not coded here. The listed conditions generally should not be reported together.
- malfunction or other complications of device - see Alphabetical Index
Excludes2
Not included here. Both codes may be reported if the patient has both conditions.
- encounter for fitting and adjustment of non-implanted device (Z46.-)
Also from chapter/block level (1 note)
- follow-up examination for medical surveillance after treatment (Z08-Z09)
Includes
Further defines or gives examples of the content of the category.
- removal or replacement of implanted device
Inclusion terms
Conditions classified to this code.
- Encounter for elective implant exchange (different material) (different size)
- Encounter for removal of tissue expander with or without synchronous insertion of permanent implant
Notes
Also from chapter/block level (3 notes)
- Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
- (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
- (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.
Alphabetic Index terms
Terms the official Alphabetic Index lists for this code. 6 entries
- Admission (for), adjustment (of), breast, implant
- Encounter (with health service) (for), adjustment and management (of), breast implant
- Encounter (with health service) (for), breast implant exchange (different material) (different size)
- Encounter (with health service) (for), removal (of), breast implant
- Encounter (with health service) (for), removal (of), breast implant, tissue expander (with or without synchronous insertion of permanent implant)
- Removal (from) (of), breast implant