Capsular contracture of breast implant, sequela

This code signifies a hardened or tightened capsule of scar tissue that forms around a breast implant, causing a range of symptoms from firmness to pain and distortion of the breast. It is a late effect or complication of the original implant surgery.

Apply this code when documenting a patient presenting with capsular contracture around a breast implant, regardless of the original reason for the implant. This code is appropriate for both initial and subsequent encounters for this condition, indicating the sequela of the implant.

• Ensure documentation clearly states "capsular contracture" and its association with a breast implant.
• The "S" at the end indicates sequela, meaning it's a late effect of the original implant procedure.
• Do not use this code for acute complications immediately following implant surgery; this is for established, chronic contracture.