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2025 ICD-10-CM code M60.2

Foreign body granuloma of soft tissue, not elsewhere classified.

Refer to the official ICD-10-CM coding guidelines for further information on proper code selection and documentation requirements.If applicable, use an external cause code following this code to specify the cause of the granuloma.

Medical necessity for treatment is established by the presence of symptoms (pain, swelling, infection), the presence of a foreign body causing inflammation, and/or the potential for complications if left untreated.The choice between medical and surgical management will depend on the specific clinical presentation.

Diagnosis is based on physical examination, imaging studies (MRI, ultrasound), and laboratory tests (ESR). Treatment may be medical management (analgesics, corticosteroids, NSAIDs) or surgical.

IMPORTANT:Use additional code to identify the type of retained foreign body (Z18.-). Excludes1: foreign body granuloma of skin and subcutaneous tissue (L92.3). Excludes2: inclusion body myositis [IBM] (G72.41)

In simple words: This code describes a lump or growth that develops in the soft tissues of the body around a foreign object that has gotten inside.This growth is caused by inflammation. It may be painful, swollen, or tender. Doctors will usually use imaging tests and blood tests to diagnose it.Treatment may include medication or surgery.

A foreign body granuloma of the soft tissues, not elsewhere classified, refers to an inflammatory nodule or tumor that forms around a foreign substance that penetrates the skin or mucous membranes.It typically presents as a firm nodule that may cause pain, swelling, or tenderness. Diagnosis is based on physical examination, imaging studies (MRI, ultrasound), and laboratory tests (ESR). Treatment may involve analgesics, corticosteroids, NSAIDs, or surgery.

Example 1: A patient presents with a firm nodule on their arm following a puncture wound from a thorn several weeks prior.Imaging shows a granuloma around the embedded thorn fragment., A patient with a history of multiple tattoos develops a raised, inflamed area around one of the tattoos, consistent with a foreign body granuloma., A patient who recently underwent surgery develops a small, painful lump near the incision site, confirmed as a granuloma surrounding a suture fragment.

Detailed history of the event leading to the foreign body, physical examination findings (location, size, consistency of nodule), imaging studies (MRI, ultrasound) to confirm the diagnosis and presence of a foreign body, laboratory results (ESR), description of any treatment provided.

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