2025 ICD-10-CM code Z18.10
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Retained foreign body fragments 21 Feed
Retained metal fragments, unspecified.
Medical necessity is established by the presence of the retained metal fragment, which may cause complications or influence patient management.
The provider is responsible for determining the presence of retained metal fragments, documenting their location if known, and ensuring appropriate coding.
In simple words: This code indicates the presence of metal pieces left in the body, with the exact location not specified. It doesn't include radioactive metal pieces.
The presence of metal fragments retained in the body, unspecified location. This code excludes retained radioactive metal fragments (Z18.01-Z18.09).
Example 1: A patient presents with a history of a metal shard entering their leg several years ago. The shard was never removed. Imaging confirms the presence of the metal fragment. Z18.10 is used to code the retained metal fragment., A patient undergoes an MRI for an unrelated condition. The MRI reveals a small metallic foreign body in the abdomen, likely from a previous injury. The patient is asymptomatic and no intervention is planned. Z18.10 is used to document the incidental finding., A patient is evaluated after an explosion. Imaging shows multiple retained metal fragments throughout their body. Z18.10 is used to code the retained metal fragments.
Documentation should include details of the retained metal fragment, such as the type of metal if known, date of initial injury or procedure, and location within the body (if known). Imaging reports confirming the presence of the fragment should also be included.
- Specialties:Radiology, Surgery, Emergency Medicine, General Practice
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Emergency Room - Hospital