Capsular contracture of breast implant, initial encounter

This code signifies a hardening or tightening of the fibrous capsule that naturally forms around a breast implant, leading to a palpable and sometimes painful breast. This contracture can distort the breast's shape and may range in severity from barely noticeable to severe and disfiguring. It is a common complication following breast augmentation or reconstruction.

Apply this code when documenting the initial diagnosis and treatment of a patient presenting with symptoms of capsular contracture around a breast implant. This includes patients undergoing their first evaluation for this condition, even if they have had previous breast surgeries. It is appropriate for both cosmetic and reconstructive breast implants.

• Ensure documentation clearly specifies "initial encounter" for the contracture.
• Do not use this code for routine follow-up care for a previously diagnosed and treated capsular contracture.
• Code any associated pain or other symptoms separately if they meet criteria for additional coding.