Capsular contracture of breast implant, subsequent encounter

This code signifies a hardened fibrous capsule forming around a breast implant, causing pain, distortion, or firmness, and is being addressed during a follow-up visit after initial treatment. It represents a complication where the body's natural healing response creates a constrictive scar tissue around the implant.

Use this code for patients presenting for subsequent evaluation or management of previously diagnosed capsular contracture of a breast implant. This includes follow-up appointments after initial surgical revision, non-surgical treatments, or for monitoring the progression of the contracture.

• Ensure documentation specifies "subsequent encounter" to justify the 7th character 'D'.
• Do not use for the initial diagnosis or treatment of capsular contracture; a different 7th character would be appropriate.
• Consider additional codes for associated symptoms (e.g., pain, breast asymmetry) if documented.