2025 ICD-10-CM code T81.5
Complications of foreign body accidentally left in body following a procedure.
Medical necessity is established when the retained foreign body causes complications requiring medical intervention.The documentation should clearly demonstrate the causal relationship between the foreign body and the subsequent complications such as infection, pain, or obstruction.
The clinician is responsible for documenting the presence of the retained foreign body, the specific complications that have arisen, and the relationship between the retained object and the complications.The clinician should also document any procedures performed to remove the foreign body or address the complications.
- 19
- Injury, poisoning and certain other consequences of external causes (S00-T88)Complications of surgical and medical care, not elsewhere classified (T80-T88)
In simple words: This code refers to problems that occur when something is accidentally left inside your body after a medical procedure.
Complications of foreign body accidentally left in body following a procedure. This code describes complications arising from a foreign object unintentionally retained in the body after a medical or surgical procedure.
Example 1: A patient undergoes an appendectomy. Several weeks later, they develop abdominal pain and an abscess. Imaging reveals a surgical sponge left in the abdominal cavity during the appendectomy., A patient has a laparoscopic cholecystectomy. Months later, they experience persistent abdominal discomfort.An X-ray reveals a surgical clip near the site of the gallbladder removal causing irritation., A patient undergoes a cesarean section. Postpartum, they develop an infection at the incision site.Examination reveals a retained surgical needle fragment as the source of the infection.
Documentation should clearly link the retained foreign body to the presenting complication(s). Imaging reports, operative notes from the original procedure, and subsequent intervention documentation should all support the T81.5 code assignment. It is necessary to document type of foreign body, location, date of initial procedure when the foreign body was retained, and the specific complication resulting from the retained foreign body.
- Specialties:General Surgery, any surgical subspecialty depending on where the original procedure that retained the foreign body occurred (e.g. Orthopedic Surgery, Cardiovascular Surgery, Neurosurgery, etc.)
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital,Off Campus-Outpatient Hospital,Ambulatory Surgical Center,Physician's Office