Retained sponge after vaginal delivery

jillian.bisbejillian.bisbe
in Clinical & Coding
Vaginal delivery with second degree laceration and repair. Postpartum day 2 patient complains of vaginal pain, retained sponge found in the vagina. How would you code this? I keep getting excludes 1 note.

Comments

  • lprescott1lprescott1
    I am not a coder- so this advice is not solid but might get you started there are codes within the t81.5 category. this might be different because it is an OB patient- I am not well versed in the guidelines related to OB.
  • 2016Optum2016Optum
    Assign O9A.23 with T81.590. AHA CC 3Q 2014 pg 35, 4Q 2014 pg 90, 1Q 2012 pg 12.
  • jillian.bisbejillian.bisbe

    Thank you!

    1Q 2012 pg 12.

    Retained sponge following vaginal delivery

    ICD-9-CM Coding Clinic, First Quarter 2012 Pages: 12-13 Effective with discharges: April 1, 2012

    Question:

    A patient, status post vaginal delivery, post delivery day two was found to have a retained sponge that was expelled from the vagina while the patient was voiding. Coding Clinic, First Quarter 2009, page 18, gives an example of a foreign body following a surgical procedure where an incision was involved. Coders are wondering if a retained sponge following a vaginal delivery should be coded differently since it is not a closed cavity. Should this sponge be reported as a retained foreign body?

    Answer:

    Yes, report code 998.4, Foreign body accidentally left during a procedure. This advice is supported by National Quality Forum (NQF) directives which state that unintended retention of a foreign object in a patient after surgery or other procedure should be reported. The occurrence of unintended retention of objects at any point after the surgery ends should be captured regardless of setting or whether the object is removed.

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