A patient with symptomatic full thickness rectal prolapse, as well as chronic constipation presents for elective laparoscopic/robotic sigmoid colectomy and rectopexy. During the rectopexy portion of the procedure, the needle was noted to become dislodged from the needle driver while attempting to pull it out. Unsuccessful attempts were made to locate the needle. An intraoperative plain film of the abdomen was performed but not helpful in locating the needle. The incision was extended to utilize hand assisted laparoscopic approach to help locate the needle, which was unsuccessful. The surgeon elected to convert to open laparotomy and was successful in retrieving the needle. The surgeon lists dislodged needle during laparoscopic suturing as a complication. Is it appropriate to assign code 998.4, Foreign body accidentally left during a procedure, for the dislodged needle? If not, what is/are the appropriate code(s) for the dislodged needle?
Assign code 998.89, Other specified complications of procedures, not elsewhere classified, since the provider listed the dislodged needle as a complication of the procedure. Do not assign code 998.4, because the needle was retrieved before surgery ended. In this case, code 996.59, Mechanical complication of other specified prosthetic device, implant, and graft, Due to other implant and internal device NEC, is not appropriate since the needle is not a prosthetic device, implant, or graft.