2025 ICD-10-CM code Z18.11
(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 (Z00-Z99) Feed
This code signifies the presence of retained magnetic metal fragments within the body.
Modifiers may be applicable based on the circumstances of the encounter and any procedures performed.Consult the most current modifier guidelines for applicable scenarios.
Medical necessity is established by the presence of retained magnetic metal fragments causing symptoms (pain, infection, etc.) or posing a risk of future complications.If removal is deemed necessary, this is justified by the clinical indications and potential negative consequences of leaving the fragments in place.
The clinical responsibility includes assessment of the retained magnetic metal fragments, evaluation of symptoms, determination of the need for removal (if any), and performance of any necessary procedure to remove the fragments. Post-procedure care and follow-up are also part of the clinical responsibility.
- Factors influencing health status and contact with health services (Z00-Z99)
- Z18.11 falls under the broader category of Z18 (Retained foreign body fragments) and the even broader chapter of Z codes (Factors influencing health status and contact with health services).
In simple words: This code is used when a person has pieces of magnetic metal inside their body that haven't been removed.The doctor uses this code to explain why the person is at the doctor's office.
ICD-10-CM code Z18.11, "Retained magnetic metal fragments," classifies the presence of magnetic metal fragments remaining in the body after an injury or procedure.This is a reason for encounter code, meaning it indicates why the patient is seeking medical attention.A procedural code should accompany it if any procedure was performed to address the retained fragments.The code excludes retained radioactive metal fragments, which are classified under separate codes (Z18.01-Z18.09).
Example 1: A patient presents to the emergency department after a workplace accident involving a magnetic tool. X-rays reveal several small magnetic metal fragments embedded in the patient's hand. Code Z18.11 is used to describe the reason for the encounter, along with a procedural code for the removal of the fragments., A patient undergoes a surgical procedure, and during the procedure, a magnetic component of a surgical instrument breaks off and remains embedded in the patient's tissue. Z18.11 is used in conjunction with codes documenting the surgical procedure and any complications related to the retained fragment., A patient experiences chronic pain and inflammation in an area where a previous injury involved magnetic metal fragments, even after initial fragments removal. The patient returns to the physician for evaluation of persistent pain and potential retained fragments. Code Z18.11 is used to document this encounter for follow-up.
Detailed medical history of the injury or procedure that resulted in retained magnetic metal fragments.Imaging studies (X-rays, MRI) showing the location and number of fragments.Documentation of any symptoms related to the retained fragments (pain, inflammation, infection).If a procedure was performed for removal, thorough documentation of the procedure, including approach, findings, and post-operative course.
** This code is primarily for encounters where retained magnetic metal fragments are the reason for the visit.If the patient is seeking care for a complication of the retained fragments (e.g., infection), additional codes may be necessary to fully capture the clinical picture.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier might apply if the procedure involves a technical component separate from the professional component. The applicability of the modifier needs to be assessed on a case-by-case basis.
- Specialties:Surgery, Emergency Medicine, Radiology, Occupational Medicine
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center