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Posted By Angie Bouchard on 01-18-2018, 20:11:04 in Ob-Gyn
I have come across a retained Nexplanon which required putting the patient under in order to obtain it as it was lost in deep fatty tissue in the arm. I had selected CPT 24201 since it was in the deep fatty tissue but cannot locate an ICD-10 code that would correctly describe this complication. Please advise & TIA for your kind assistance.

DESCRIPTION OF OPERATION: Under adequate general anesthesia, the patient was properly prepped and draped using routine manner using aseptic technique, prepping her left arm. Her left arm was placed out so that
the area of the Nexplanon could be easily palpated. The Nexplanon was not palpable. Review of the x-ray revealed it to be in the left upper arm. A skin incision made at the site of her previous incision, extended through skin and subcutaneous tissue. The Nexplanon could not be palpated. Exploration with a hemostat finally revealed the tip of the Nexplanon deep into the fatty tissue. It was grasped and removed without issues. The subcutaneous tissues then closed using an interrupted suture of 3-0 Monocryl suture and the skin was closed with a subcuticular stitch of 4-0 Monocryl suture and Dermabond solution and wrapped in a Coban wrap. The operation was complete. Final sponge and needle counts were correct. Patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
Comments (1)
Posted By Melanie Witt on 01-22-2018, 17:46:43
I assume this was to have been a routine removal, but was complicated due to its movement from the original position. You have 2 options, M79.5 or T85.628_. The T code implies is was removed due to a complication, not just where it was located.
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