AHA Coding Clinic® for ICD-9 - 2014 Issue 1; Ask the Editor

Retained Laparotomy Sponge during Cesarean Delivery

The patient underwent emergent low transverse cesarean section due to non-reassuring fetal heart rate and persistent bradycardia. At delivery, the infant was pronounced dead after 21 minutes of attempted resuscitation. Sponge counts during surgery were deferred as there was no initial count, with plans for post-operative x-ray. The postoperative x-ray was notable for findings suggestive of retained laparotomy sponge. The patient was reopened in the operating room and a retained lap sponge was removed without complication. At the beginning of the Complications of surgical and medical care NEC (996-999) categories, there is an instructional note excluding complications of surgical procedures during abortion, labor and delivery (630-676.9). Therefore, is code 998.4, Foreign body accidentally left during a procedure, reported, or would a code from Chapter 11 Complications of pregnancy, childbirth, and the puerperium (630-679) be more appropriate? How should this case be coded? ...

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