2025 ICD-10-CM code Z18.9
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Retained foreign body fragments 21 Feed
The patient has retained foreign body fragments of unspecified material.
Medical necessity for using Z18.9 must be supported by documentation of the presence of the retained foreign body and the clinical significance of its presence. If a procedure is performed related to the retained fragment, a procedure code should also be reported.
Clinicians should document the location of the retained fragment, any associated symptoms, and any plans for removal or monitoring. It is essential to distinguish this condition from foreign bodies accidentally left during a procedure (T81.5-), foreign bodies entering through an orifice (T15-T19), or superficial foreign bodies (non-embedded splinters).
In simple words: This code indicates the presence of foreign material left inside the body after an injury or procedure, with the specific material being unknown.
Retained foreign body fragments, unspecified material. This code is used when a foreign body fragment remains embedded in the body and the material of the fragment is unknown.It includes embedded fragments and splinters.
Example 1: A patient presents with a retained wood splinter in their finger, but the type of wood is unknown. The splinter is embedded and requires removal., Following a motor vehicle accident, a patient has retained glass fragments embedded in their arm. The exact type of glass is undetermined., A child swallowed a small object, and imaging reveals a fragment lodged in the esophagus. However, the material of the swallowed object cannot be identified from the imaging results.
Documentation should include details of how the foreign body was acquired, the location of the retained fragment, the approximate size and shape of the fragment if known, associated symptoms, and the plan of care (e.g., removal, monitoring).
** Excludes1: artificial joint prosthesis status (Z96.6-), foreign body accidentally left during a procedure (T81.5-), foreign body entering through orifice (T15-T19), in situ cardiac device (Z95.-), organ or tissue replaced by means other than transplant (Z96.-, Z97.-), organ or tissue replaced by transplant (Z94.-), personal history of retained foreign body fully removed (Z87.821), superficial foreign body (non-embedded splinter) - code to superficial foreign body, by site.
- Payment Status: Active
- Specialties:Emergency Medicine, General Surgery, Internal Medicine, Pediatrics, Family Medicine
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Other Place of Service