Document breast implant status accurately with appropriate medical coding and clinical documentation. This resource provides guidance on capturing breast implant history, including post breast implant surgery details, for precise healthcare records and billing. Learn about best practices for recording breast implant information in patient charts and ensure compliant coding for breast implant-related procedures and diagnoses.
Also known as
Other specified postprocedural states
Presence of breast implants, not causing symptoms.
Other complications of internal prosth dev/grft
Complications due to breast implants, like capsular contracture.
Encounter for prophylactic surgery
Follow-up encounters for prophylactic mastectomy with implant reconstruction.
Follow this step-by-step guide to choose the correct ICD-10 code.
Does the patient have breast implants?
Yes
Any complications or related conditions?
No
Implants previously removed?
When to use each related code
| Description |
|---|
| Status of breast implants, including presence, type, and complications. |
| Rupture or leakage of a breast implant requiring intervention. |
| Capsular contracture, a complication of breast implants. |
Unspecified implant type (saline, silicone, other) leads to coding and reimbursement issues. CDI should query for clarity.
Missing laterality (unilateral, bilateral) impacts coding accuracy and can affect medical necessity reviews.
Confusing implant status with implant complications (e.g., rupture) can lead to incorrect code assignment and audits.
Q: How can I accurately document and track breast implant status, including type, placement, and complications, in my patient's electronic health record (EHR)?
A: Accurate documentation of breast implant status is crucial for patient safety and long-term follow-up. To effectively track implant type (e.g., saline, silicone gel, textured), placement (subglandular, submuscular), and any complications (e.g., capsular contracture, rupture) within the EHR, consider implementing a standardized template or structured data field. This ensures consistent data collection across patients. Documenting the manufacturer, model, and serial number of the implants is also essential for device identification and potential recalls. Furthermore, consider incorporating imaging reports (mammography, ultrasound, MRI) directly into the EHR to provide a comprehensive overview of the patient's breast implant history. Explore how integrating standardized terminology, like SNOMED CT, can further enhance data interoperability and facilitate research related to breast implant outcomes. Learn more about best practices for breast implant documentation and EHR integration.
Q: What are the key considerations for post-breast implant surgery follow-up care, including recommended imaging frequency and managing potential complications like BIA-ALCL?
A: Post-breast implant surgery follow-up care requires a multi-faceted approach. Routine follow-up visits should include physical exams and patient-reported outcome measures. Adherence to recommended imaging protocols is vital. While MRI is considered the gold standard for detecting silent rupture, the frequency and modality of imaging (MRI, ultrasound, mammography) may vary depending on patient-specific factors and implant type. Patient education on potential complications, such as capsular contracture, rupture, and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), is paramount. Clinicians should be vigilant in recognizing early signs and symptoms of BIA-ALCL, including persistent seroma, pain, asymmetry, or lymphadenopathy. Consider implementing a standardized patient education program that addresses both routine post-operative care and specific concerns related to BIA-ALCL. Explore the latest research on BIA-ALCL diagnosis and management to ensure optimal patient care.
Patient presents for evaluation of breast implant status. Relevant medical history includes breast augmentation surgery performed on [Date of surgery] with placement of [Type of implant: saline or silicone] implants, size [Implant size], [Implant shape: round or anatomical] shape, placed [Implant location: subglandular or submuscular]. Patient reports [Symptom: e.g., no symptoms, pain, asymmetry, changes in sensation, implant rupture symptoms such as rippling or deflation]. Physical examination reveals [Findings: e.g., breasts are symmetrical, palpable implants without evidence of rupture, capsular contracture grade [Grade if applicable], skin changes]. Assessment includes breast implant integrity, capsular contracture, and overall cosmetic outcome. Current concerns include [Patient concerns: e.g., desire for implant removal, replacement, or revision, concerns regarding implant safety, questions about MRI screening]. Plan includes [Plan: e.g., continued surveillance, referral to plastic surgery for consultation, ordering breast MRI, discussion of risks and benefits of various treatment options including implant removal, capsulectomy, or replacement]. Patient education provided regarding breast implant complications, potential long-term effects, and follow-up recommendations. ICD-10 code [Appropriate ICD-10 code, e.g., Z98.89 Other specified postsurgical states] is considered for this encounter. This documentation supports medical necessity for the evaluation and management of the patient's breast implant status.