AHA Coding Clinic® for ICD-9 - 2011 Issue 1; Ask the Editor

Broken Needle Left during Surgery

During surgery a needle was placed along the right lateral aspect of the sewing ring of the aortic valve and passed through tissue deep in the recess between the aortic root and the left atrium to try to cinch the valve down. The suture broke from the needle and the needle was lost within this tissue. Multiple attempts to find it were unsuccessful. An x-ray was obtained which did not reveal the needle. The chest was closed and a second x-ray showed that the needle was where the surgeon thought, to the right of the aortic valve. The chest was reopened but the needle still could not be located or palpated. The surgeon decided that continuing to look for the needle was likely to cause the patient more harm than good. Therefore, the chest was reapproximated and the patient was transferred to ICU in stable condition. What is the correct diagnosis code assignment when a provider intentionally leaves a foreign body in the patient and the documentation clearly states that removing the foreign body will cause more harm than good? Would code 998.4, Foreign body accidentally left during procedure, be appropriate? ...

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