InnovaRx Innova Health Strategies

Z45.812

Encounter for adjustment or removal of left breast implant

Billable FY2026 2025-10-01 → 2026-09-30
Exclusions 3 never code together
Z45code
Excludes1
  • malfunction or other complications of device - see Alphabetical Index
Excludes2
  • encounter for fitting and adjustment of non-implanted device (Z46.-)Z46.-
Z40-Z53block
Excludes2
  • follow-up examination for medical surveillance after treatment (Z08-Z09)Z08-Z09

Excludes1 — never code together. The excluded condition and this one are mutually exclusive.

Excludes2 — not included here, but the patient may have both. Code both when documented.

Instructional notes 5
Z45code
Includes
  • removal or replacement of implanted device
Z40-Z53block
Inclusion terms
  • Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual stateZ40-Z53
Z00-Z99chapter
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:Z00-Z99A00-Y89
  • (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.
Index entries leading here 3 filed at Z45.81

The index files this at Z45.81. The tabular extends it — laterality, staging, or the 7th character — so these entries lead to the family rather than to Z45.812 exactly.

  • Encounter (with health service) (for) Z76.89
    • adjustment and management (of)
    • removal (of) — see also Removal
      • breast implant Z45.81
        • tissue expander (with or without synchronous insertion of permanent implant) Z45.81
    • breast implant exchange (different material) (different size) Z45.81
  • Admission (for) — see also Encounter (for)
    • adjustment (of)
  • Removal (from) (of)
Alongside this code 2 same parent — Z45.81
Additional references
AHA Coding Clinic® Licence required

Official coding advice for this code. Published by the American Hospital Association. Not included in this installation.

Risk adjustment

Maps to no condition category in any loaded model.

Presence is a property of the code. Untick a model to hide it everywhere.

This code

Billable
yes
Code set
FY2026
Parent
Z45.81
Block
Z40-Z53
Siblings
2

Present FY2024–FY2027.