Z45.81
Header — not billableEncounter for adjustment or removal of breast implant
The ICD-10 code for encounter for adjustment or removal of breast implant is Z45.81.
Z45.81 is a non-billable header code. It groups related conditions but cannot be used on its own for reimbursement — select one of the 3 more specific codes below.
Clinical notes
Excludes1 (not coded here)
An Excludes1 note is a pure exclusion: the excluded condition and this code should never be reported together, because the two conditions cannot occur at the same time (e.g. a congenital form vs. an acquired form of the same disease).
Also known as
Alternate wording, synonyms, or specific conditions that fall under this code, listed to help confirm you've picked the right one.
- Encounter for elective implant exchange (different material) (different size)
- Encounter for removal of tissue expander with or without synchronous insertion of permanent implant
Documentation support
General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.
- •This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
- •Confirm the excluded condition(s) listed above are not also present — Excludes1 conditions cannot be coded together with this one.
- •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.
Related codes in this category
- Z45.82Encounter for adjustment or removal of myringotomy device (stent) (tube)
- Z45.89Encounter for adjustment and management of other implanted devices
- Z45.81Encounter for adjustment or removal of breast implantnon-billable header