Intentional Retainment of Foreign Body

This month, “In the kNOW” is going to explore the appropriate ICD-10-CM code assignment when a foreign body is intentionally left in the body. Now, you may be wondering why a provider would ever leave a foreign body intentionally in a patient’s body. Consider this. If, during an open reduction internal fixation fracture procedure, a drill bit breaks off in a patient’s bone, the provider must weigh the risks to the patient of trying to remove the foreign body as opposed to leaving it in situ. In some circumstances, the foreign body might easily be removed and not pose significant risk to the patient. However, in other cases, perhaps influenced in part by the patient’s age, time under anesthesia, or other factors, the provider may deem it in the best interest of the patient to leave that foreign body where it is. Now comes the challenging part for a coding professional, how do we code that? 

Our first instinct is probably to assign a complication code such as T81.590A-Other complications of foreign body accidentally left in body following surgical operation, initial encounter. However, a review of the 2nd Qtr. 2025 Coding Clinic, would tell us that is incorrect. Instead, we should assign Y65.4 -Failure to introduce or to remove other tube or instrument.

That same Coding Clinic explains this advice is consistent with the National Quality Forum listing of Serious Reportable Events. Appendix A of that list addresses unintended foreign body retention but excludes from reporting objects like broken drill bits or screws, that are intentionally left in when the risk of removal is greater than the risk of retention. 

Now you are In the kNOW!!

About the Author

Dianna Foley, RHIA, CCS, CDIP, CHPS, has 25 years of HIM experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA. Dianna’s an AHIMA-approved ICD-10-CM/PCS trainer, an AHIMA-published author, a participant in AHIMA credential item writing and exam development, and served on the AHIMA Nominating Committee. Dianna has held various HIM positions and is now an independent coding consultant. She previously served as a program director for Medical Coding and HIT. She presents on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator.