2025 ICD-10-CM code Z18.1
Presence of retained metal fragments in a patient. This code excludes retained radioactive metal fragments.
Medical necessity is established by the presence of retained metal fragments and any associated symptoms, complications, or potential risks they pose to the patient's health.
The provider is responsible for documenting the presence of the retained metal fragments, their location, and any associated symptoms or complications.Further investigation or removal may be necessary depending on the specific circumstances.It's crucial to distinguish between retained fragments and foreign bodies accidentally left during a procedure, which uses a different code.
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- Z18 - Retained foreign body fragmentsZ18.1 - Retained metal fragments
In simple words: This code indicates the presence of non-radioactive metal pieces left in the body after an injury or surgery.
The presence of metal fragments retained within the body. This code should be used when a patient has metal fragments remaining after an injury or procedure. It excludes retained radioactive metal fragments, which are classified under Z18.0.
Example 1: A patient presents with ongoing discomfort following a previous injury where shrapnel was embedded in their leg. Imaging confirms the presence of retained metal fragments., Following a surgical procedure, a small metal fragment from a surgical instrument is discovered on a postoperative X-ray, although the patient is currently asymptomatic., A patient who had a previous injury from an exploding firework experiences chronic pain and inflammation.Imaging reveals retained metal fragments from the firework.
Documentation should include details of the original incident or procedure, the type of metal, location of the fragments, size and number of fragments if known, and any related symptoms or complications.
** This code is used for aftercare encounters when the retained fragment is not causing any active problems but requires ongoing monitoring. If the fragment requires removal or further treatment, additional codes should be used to describe those procedures. It is essential to differentiate Z18.1 from Z87.821 (Personal history of retained foreign body fully removed).
- Specialties:Surgery, General Practice, Orthopedics, Emergency Medicine, Radiology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Office, Other Place of Service