2025 ICD-10-CM code Z18
(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 Factors influencing health status and contact with health services Feed
This code signifies the presence of retained foreign body fragments within the patient's body.
Modifiers may apply depending on the circumstances of the procedure performed to remove the foreign body. Consult the CPT and HCPCS modifier guidelines for specifics.
Medical necessity for coding Z18 is established by the presence of a retained foreign body that requires observation, treatment, or removal. The clinical significance is based on the potential for complications such as infection, inflammation, or obstruction. Documentation must support the clinical need for any procedures performed.
The clinical responsibility for code Z18 rests with the physician or healthcare provider managing the patient's condition involving the retained foreign body. This responsibility includes assessing the foreign body's nature, location, potential complications, and deciding on a course of action (observation, removal, or other treatment).
In simple words: This code means that a piece of something that doesn't belong in the body (like a splinter or a small piece of metal) is still inside after an injury or operation.The doctor uses this code to note the presence of the foreign object.A different code is used to show what type of object it is and where it is located in the body.
ICD-10-CM code Z18, "Retained foreign body fragments," is used to classify the presence of foreign material remaining in the body after an event or procedure.This includes embedded fragments, splinters, or other foreign bodies.It's crucial to note that this code does not classify the foreign body itself, only its status of being retained.Further codes should be used to specify the type and location of the foreign body (e.g., Z18.0 for retained radioactive fragments, Z18.1 for retained metal fragments), and a procedure code should accompany Z18 if a procedure to remove the foreign body was performed. Excluded are foreign bodies accidentally left during a procedure (coded elsewhere), foreign bodies entering through an orifice (coded elsewhere), and superficial foreign bodies (coded according to their site).
Example 1: A patient presents to the emergency department after a workplace accident with a metal splinter embedded in their hand. The physician removes the splinter.Code Z18.1 (Retained metal fragments) would be used in conjunction with the procedure code for splinter removal., A patient undergoes surgery, and a small surgical sponge is inadvertently left inside during the procedure.The patient returns for a second surgery to remove the sponge.Code Z18 would be used with the procedure code for removal of a retained foreign body., A patient with a history of a gunshot wound presents for routine follow-up.Imaging reveals a small, non-migratory metal fragment remaining from the original injury.Code Z18.1 would be documented along with imaging codes, as no intervention is needed at this time.
Documentation should include details on the nature of the foreign body (e.g., type of material, size, shape), its location, how it was acquired (e.g., accident, surgery), clinical presentation, images (x-ray, ultrasound, CT scan) showing the foreign body, and the decision regarding management (observation, removal).If a procedure is performed, detailed operative notes are essential.
** Code Z18 should only be used when the foreign body is retained and not fully removed.If the foreign body is completely removed, a different code might be more appropriate. This code should be used in conjunction with other codes describing the specific foreign body, its location, and any procedures performed.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier may be applicable if the services are split between professional and technical components, in accordance with CPT and HCPCS guidelines.
- Specialties:Emergency Medicine, Surgery (various subspecialties), Radiology
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center