2025 ICD-10-CM code Z18.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Factors influencing health status and contact with health services - Retained foreign body fragments Chapter 21: Factors influencing health status and contact with health services Feed
This code classifies the presence of retained plastic fragments within the body.
Modifiers may be applicable depending on the circumstances of the encounter and any procedures performed.Consult the official guidelines for modifier use.
Medical necessity for any procedure related to retained plastic fragments is based on the presence of symptoms (e.g., pain, infection), potential for future complications (e.g., migration, infection), or the patient's preference to have the fragments removed for cosmetic reasons.Documentation must support medical necessity.
The clinical responsibility lies with the physician managing the patient's overall care. This may involve monitoring for complications related to the retained fragment, managing any symptoms, or planning for its removal.
- Chapter 21: Factors influencing health status and contact with health services
- Z18-Z18.9: Retained foreign body fragments
In simple words: This code means that small pieces of plastic are left inside the body after an accident or surgery.The doctor notes this on your record, even if it's not causing any problems right now.
ICD-10-CM code Z18.2, "Retained plastic fragments," is used to indicate the presence of plastic fragments remaining in the body after a procedure or injury.This code is assigned when the fragments are not causing active disease or injury, but their presence is documented.It's crucial to distinguish this from codes describing active infection or complications resulting from the retained fragments.The code is used for encounters focused on the presence of these fragments, possibly for observation or future removal.This code should be accompanied by a procedure code if a procedure to remove the fragments is performed.Z18.2 is exempt from the "Present on Admission" (POA) reporting requirement.
Example 1: A patient presents following a motor vehicle accident with retained plastic fragments from a shattered car interior component embedded in their leg.The fragments are not causing infection or significant discomfort but are documented for observation and potential future removal., During a surgical procedure, a small piece of plastic from a surgical instrument is inadvertently left behind. The plastic is not causing immediate problems, so it is documented with Z18.2, pending a follow-up appointment to consider removal., A patient undergoes a previous surgery resulting in retained plastic from a medical device.During a routine checkup, the retained fragment is noted. The physician might recommend a follow-up, monitor for infection or inflammation, or decide on intervention based on individual risk.
The medical record must clearly document the presence of retained plastic fragments.It should specify the location, size, and any associated symptoms or complications.Images (X-ray, CT scan) showing the fragments are beneficial. If a procedure was performed for removal, the operative report should describe the procedure and the removal of the fragment.
** The size and location of the retained fragments are not specified in the code, but this information should be clearly documented in the medical record. If the retained fragments are from a specific device, additional codes to note the foreign body's presence might be appropriate (such as codes for implants or internal medical devices).The presence of the plastic fragments does not necessarily mean that a procedure is needed; it might just be a note on the patient's record.
- Payment Status: Active
- Modifier TC rule: Not applicable to this diagnosis code.
- Specialties:General Surgery, Plastic Surgery, Orthopedics, Emergency Medicine
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital, Inpatient Hospital