Facing breast implant complications or breast prosthesis complications? Find information on diagnosing and documenting breast implant issues, including capsular contracture, rupture, and BIA-ALCL. Learn about relevant ICD-10 codes, SNOMED CT concepts, and clinical documentation best practices for accurate healthcare reporting and coding related to breast implant complications. This resource offers guidance for medical professionals on proper terminology and coding for breast implant-related problems.
Also known as
Mechanical complication of breast implant
Problems related to the physical breast implant.
Complications of pregnancy, childbirth and the puerperium
Issues related to pregnancy impacting breast implants.
Granulomatous disorders of skin and subcutaneous tissue
Skin reactions and inflammatory responses around the implant.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the complication mechanical?
Yes
Implant rupture or leak?
No
Infection or inflammation present?
When to use each related code
| Description |
|---|
| Problems related to breast implants. |
| Tightening of scar tissue around a breast implant. |
| Break or tear in a breast implant shell. |
Lack of documentation specifying saline vs. silicone, textured vs. smooth, or manufacturer details can lead to inaccurate coding and claims.
Unilateral vs. bilateral implant complications require distinct codes. Missing laterality information causes coding and billing errors.
Distinguishing between a device malfunction (e.g., rupture) and a resulting complication (e.g., infection) is crucial for proper code assignment.
Q: What are the early and late signs of breast implant-associated ALCL (BIA-ALCL) that clinicians should be aware of, and how can these be differentiated from other common post-implantation complications?
A: Early signs of BIA-ALCL often present as persistent seroma, typically occurring years after breast implant surgery (median of 7-10 years). Clinicians should be vigilant for swelling, pain, asymmetry, or a palpable mass around the implant, which can mimic infection or capsular contracture. Late-stage BIA-ALCL can manifest as lymphadenopathy, skin lesions, or B symptoms. Differentiating BIA-ALCL requires careful evaluation. While ultrasound can detect seroma, it's crucial to aspirate the fluid for cytology. If cytology suggests ALCL, immunohistochemistry staining for CD30 is confirmatory. Consider implementing a standardized post-implant follow-up protocol that includes patient education about potential complications and regular clinical exams to facilitate early detection. Explore how incorporating detailed patient history taking, including implant type and texture, can aid in risk assessment.
Q: How can clinicians effectively manage capsular contracture in patients with breast implants, including non-surgical and surgical treatment options, and when is referral to a specialist indicated?
A: Capsular contracture management depends on its severity (Baker grade). Non-surgical approaches, such as manual massage or ultrasound therapy, may be considered for milder cases (Baker grades I-II). For more severe contracture (Baker grades III-IV), surgical intervention like capsulectomy or capsulotomy is often necessary. Clinicians should discuss the risks and benefits of each option with patients, taking into account their individual preferences and medical history. Referral to a plastic surgeon specializing in breast implant revision is warranted for complex cases, recurrent contracture, or suspected implant rupture concurrent with capsular contracture. Learn more about the latest advancements in capsular contracture prevention, such as the use of textured implants or acellular dermal matrix, to optimize patient outcomes.
Patient presents with concerns related to breast implant complications. She reports experiencing [Symptom 1, e.g., persistent pain in the right breast], [Symptom 2, e.g., capsular contracture], and [Symptom 3, e.g., changes in breast shape]. Onset of symptoms began approximately [Timeframe, e.g., three months] ago and have [Progression, e.g., gradually worsened]. Patient denies any fever, chills, or nipple discharge. Medical history includes bilateral breast augmentation performed [Date] with [Implant type, e.g., silicone gel implants]. Physical examination reveals [Objective findings, e.g., palpable firmness in the upper outer quadrant of the right breast, asymmetry]. Differential diagnosis includes capsular contracture, implant rupture, breast implant illness, infection, and seroma. Preliminary diagnosis of [Specific complication, e.g., Baker grade III capsular contracture] is made based on patient history and physical examination. Ordered [Diagnostic tests, e.g., breast ultrasound, MRI] to further evaluate the integrity of the implants and rule out other potential causes. Patient education provided regarding the risks and benefits of various treatment options, including [Treatment options, e.g., capsulectomy, implant removal, implant replacement]. Follow-up appointment scheduled in [Timeframe, e.g., two weeks] to review imaging results and discuss the treatment plan. ICD-10 code T85.89XD for other complications due to other internal prosthetic devices, implants and grafts is considered pending further evaluation. CPT codes for the consultation and diagnostic imaging will be documented accordingly.