Z45.819Encounter for adjustment or removal of unspecified breast implant

Z45.819 is the ICD-10-CM diagnosis code for encounter for adjustment or removal of unspecified breast implant. It belongs to category Z45 (encounter for adjustment and management of implanted device), block Z40-Z53 (Encounters for other specific health care) and chapter 21 (factors influencing health status and contact with health services). It is billable, so it can be reported on its own for dates of service from October 1, 2026 through September 30, 2027.

Within Z45.81, choose Z45.819 (unspecified breast implant) only when documentation doesn't support a more specific option: right breast implant (Z45.811) and left breast implant (Z45.812).

It is not a CC or MCC, so as a secondary diagnosis it doesn't change the MS-DRG severity level.

In MS-DRG v44.0, it is part of the grouping logic for DRG 951 (Other Factors Influencing Health Status, relative weight 0.5577), in MDC 23 (Factors Influencing Health Status and Other Contacts with Health Services), as a principal or secondary diagnosis. The DRG a claim lands in depends on the principal diagnosis, procedures and any CC/MCC secondary diagnoses.

It is exempt from present-on-admission (POA) reporting, so no POA indicator is required.

It has been part of ICD-10-CM since the code set took effect on October 1, 2015 and hasn't changed since.

Before ICD-10, this condition was coded in ICD-9-CM as V52.4 (fitting and adjustment of breast prosthesis and implant).