Z45.81
Encounter for adjustment or removal of breast implant
Not billable — category only FY2026 2025-10-01 → 2026-09-30
Exclusions 6 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.-
Z45.81code
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 7
Z45code
Includes
- removal or replacement of implanted device
Z45.81code
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
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
Alongside this code 2 same parent — Z45.8
Subordinate codes 3
Additional references
AHA Coding Clinic® Licence required
Official coding advice for this code. Published by the American Hospital Association. Not included in this installation.