Z45.81 is the authoritative medical code for Encounter for adjustment or removal of breast implant. This classification is used in medical billing and clinical recording to specify the clinical criteria for encounter for adjustment or removal of breast implant (ICD-10-CM Z45.81), ensuring healthcare documentation aligns with current federal coding standards.
Billing Status: NO. This is a clinician non-billable / parent hierarchy grouping in the ICD-10-CM system.
Official Registry Overview & Definition
Encounter for adjustment or removal of breast implant is a non-billable ICD-10-CM category code Z45.81. A more specific billable subcode must be selected for claims submission. Includes: removal or replacement of implanted device. Inclusion terms: Encounter for elective implant exchange (different material) (different size); Encounter for removal of tissue expander with or without synchronous insertion of permanent implant. Excludes1 (not coded here): complications of breast implant T85.4-; encounter for initial breast implant insertion for cosmetic breast augmentation Z41.1; encounter for breast reconstruction following mastectomy Z42.1; malfunction or other complications of device - see Alphabetical Index. Excludes2 (not included here): encounter for fitting and adjustment of non-implanted device Z46.-; follow-up examination for medical surveillance after treatment Z08-Z09.
Official Tabular Instructional Notes
Sequencing, inclusion, and exclusion notes published for Z45.81 in the official ICD-10-CM tabular list.
Includes
Conditions the official ICD-10-CM tabular list includes under this code.
- removal or replacement of implanted device
Inclusion Terms
Alternative terms the tabular list files under 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
Excludes1 — Not Coded Here
Conditions that can never be reported with this code; the two are mutually exclusive.
- complications of breast implant T85.4-
- encounter for initial breast implant insertion for cosmetic breast augmentation Z41.1
- encounter for breast reconstruction following mastectomy Z42.1
- malfunction or other complications of device - see Alphabetical Index
Excludes2 — Not Included Here
Conditions not covered by this code, but which may be reported alongside it when both are present.
- encounter for fitting and adjustment of non-implanted device Z46.-
- follow-up examination for medical surveillance after treatment Z08-Z09
Frequently Asked Questions (FAQ) & Clinical Guidance
Can Z45.81 be billed directly?
No. Z45.81 (Encounter for adjustment or removal of breast implant) is a non-billable ICD-10-CM category code. A more specific billable subcode must be selected based on clinical documentation.
What can't be coded together with Z45.81?
Per official ICD-10-CM Excludes1 instructions, Z45.81 must not be reported together with: complications of breast implant (T85.4-); encounter for initial breast implant insertion for cosmetic breast augmentation (Z41.1); encounter for breast reconstruction following mastectomy (Z42.1); malfunction or other complications of device - see Alphabetical Index.
Can Z45.81 be reported alongside related conditions?
Per official ICD-10-CM Excludes2 instructions, Z45.81 and the following are not considered part of each other and may both be reported when both conditions are present: encounter for fitting and adjustment of non-implanted device (Z46.-); follow-up examination for medical surveillance after treatment (Z08-Z09).
What conditions are included under Z45.81?
Encounter for adjustment or removal of breast implant includes: Encounter for elective implant exchange (different material) (different size); Encounter for removal of tissue expander with or without synchronous insertion of permanent implant.
Nearest Codes in This Family
Official ICD-10-CM classifications closest to Z45.81 in its code family, with their registry titles.
- Z45.811 — Encounter for adjustment or removal of right breast implant
- Z45.812 — Encounter for adjustment or removal of left breast implant
- Z45.819 — Encounter for adjustment or removal of unspecified breast implant
Indexed Clinical Terms (6)
Clinical term phrases from the official ICD-10-CM Index to Diseases and Injuries that map to this code.
- 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