2025 ICD-10-CM code T81.530
Perforation due to a foreign body accidentally left in the body following a surgical operation.
Medical necessity for the treatment of the perforation is established by the presence of the retained foreign body and the associated complications. The documentation should clearly demonstrate the causal relationship between the foreign body and the perforation.
The physician is responsible for documenting the presence of the retained foreign body, the specific organ perforated, and the causal relationship between the retained object and the perforation. The documentation should also include details of the initial surgery and the subsequent intervention to address the perforation.
In simple words: A tear or hole in an organ caused by a foreign object accidentally left inside the body after surgery.
Perforation due to a foreign body accidentally left in the body following a surgical operation.
Example 1: A patient undergoes a laparoscopic appendectomy. Several weeks later, the patient presents with abdominal pain and fever. Imaging reveals a retained surgical sponge and a perforated bowel. The sponge is removed, and the perforation is repaired., During a hysterectomy, a surgical instrument breaks, and a small piece is inadvertently left inside the patient. Months later, the patient develops pelvic pain and abscess formation due to the retained fragment perforating the bladder. The foreign body is removed, and the bladder is repaired., A patient undergoes a coronary artery bypass graft. A small piece of surgical material is left behind near the heart. Years later, the patient experiences chest pain and pericarditis. The retained material is found to have perforated the pericardium. The foreign body is removed, and the pericardium is treated.
Documentation should include operative reports of the original surgery and the subsequent procedure to address the perforation, imaging studies confirming the retained foreign body and the perforation, and clinical findings supporting the diagnosis.
** This code specifically addresses perforations caused by retained foreign bodies following a surgical operation. It excludes complications of other medical procedures, such as punctures or lacerations.
- Specialties:General surgery, surgical subspecialties (e.g., cardiovascular, gynecological, etc.)
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center