2025 ICD-10-CM code T81.6
(Active) Effective Date: N/A Revision Date: N/A Injury - Complications of surgical and medical care, not elsewhere classified (T80-T88) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Acute reaction to a foreign substance accidentally left during a procedure.
Modifiers may be necessary depending on the circumstances of the procedure and the site of service.Review the specific guidelines for applicable modifiers.
Medical necessity is established by the presence of an acute reaction directly resulting from a retained foreign object following a medical or surgical procedure.The reaction must necessitate further medical intervention (e.g., removal of the object and treatment of the ensuing complications).
The clinical responsibility for this code rests primarily with the surgeon or physician performing the original procedure during which the foreign body was inadvertently left.Post-operative care, diagnosis and management of the acute reaction might involve other specialties depending on the nature and severity of the reaction.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- T81.6 falls under the broader category of T81 (other specified complications of surgical and medical care) and the even broader category of T80-T88 (complications of surgical and medical care, not elsewhere classified). It sits within Chapter 19 of the ICD-10-CM classification system.
In simple words: This code describes a sudden reaction to something accidentally left inside the body during a medical procedure.It covers problems that happen soon after the procedure because of this foreign object.
This code classifies an acute reaction resulting from a foreign substance unintentionally left behind during a medical or surgical procedure.It encompasses immediate or short-term adverse effects stemming from the retained foreign material.The code excludes complications that develop later or are related to the foreign body's presence in a body cavity or surgical wound following the procedure itself.Additional codes may be necessary to specify the foreign body, the resulting condition, and the external cause (from Chapter 20, External causes of morbidity).
Example 1: A patient undergoes abdominal surgery, and a surgical sponge is inadvertently left in the abdomen. The patient develops an acute inflammatory reaction within hours of the surgery, requiring additional intervention to remove the sponge and manage the inflammation.Code T81.6 would be used to represent the acute reaction to the retained sponge., A patient receives a dental implant, and a small metallic fragment breaks off during the procedure and remains embedded in the gum tissue.The patient experiences immediate localized pain and swelling. Code T81.6 would apply, along with codes to identify the foreign body (Z18.-) and the specific injury caused by it., During a laparoscopic cholecystectomy, a small piece of a surgical instrument tip is inadvertently left in the patient’s gallbladder. Following the procedure, the patient presents with localized abdominal pain, fever, and elevated white blood cell count, indicating an acute inflammatory reaction.Code T81.6 would be utilized, along with codes specifying the retained foreign body (Z18.-) and the surgical procedure performed.
Detailed operative report documenting the procedure and the inadvertent retention of the foreign object.Post-operative notes describing the acute reaction, including symptoms, vital signs, and laboratory results (e.g., complete blood count with differential, inflammatory markers).Radiological images (e.g., X-ray, CT scan) confirming the presence and location of the retained foreign substance.Documentation of the removal of the foreign body and the patient's response to treatment.
** This code should be used cautiously and only when an acute reaction is directly attributable to the foreign body.The timing of the reaction is crucial in determining the appropriate code assignment.If the reaction occurs later and is not considered acute, other codes may be more appropriate.
- Payment Status: Active
- Modifier TC rule: Not applicable
- Specialties:Surgery, General Surgery, Internal Medicine, Emergency Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center