Perf due to fb acc left in body fol unsp procedure, subs

This code signifies a perforation that has occurred as a direct consequence of a foreign body, such as a surgical sponge or instrument, being inadvertently retained within a patient's body after an unspecified medical procedure. The perforation is a delayed complication of the retained foreign object, indicating a subsequent encounter for this issue.

Apply this code when documentation clearly indicates a patient presenting with a perforation caused by a foreign body that was accidentally left inside following a prior procedure, and this is not the initial encounter for the retained foreign body itself. This would be used for follow-up care, treatment, or management of the perforation.

• Always sequence this code after the appropriate T81.53x code for the retained foreign body itself, if applicable and still present.
• Ensure the documentation specifies "perforation" and links it directly to the retained foreign body, not just a general complication.
• Verify that this is a "subsequent encounter" for the perforation, meaning the patient is receiving ongoing care for this specific complication.