Retained Foreign Body, Encounter For and External Cause

Retained Foreign Body

Retained Foreign Body

 

• Specify type of foreign body retained, examples:
    --Glass
    --Metal
    --Radioactive
    --Tooth
    --Other (specify)

External Cause

• Document “how” an injury occurred, such as fall, motor vehicle
accident, etc.
• Document “where” an injury occurred, such as home, work, school, etc.
• Document “activity”, such as skiing, ironing, gardening, etc.
• Document “status”:
    --Civilian
    --Military
    --Volunteer
    --Other (specify)
• Important Notes:
    --No national requirement for external cause reporting
    --Some states and payers require external cause codes

Encounter For

• Document the reason for encounter, such as:
    --Examination
    --Pregnancy
    --Adjustment/removal of device
    --Suspected condition, ruled out
    --Other (specify)

History (Personal and Family)

• Document any relevant personal/family history, such as:
    --Malignant neoplasm (specify type)
    --Congenital malformations/deformations (specify type)
    --Allergies (specify type)
    --Chemotherapy
    --Radiation therapy
    --Surgical history
    --Other (specify)

Genetic Carrier/Susceptibility

• Specify genetic carrier of:
    --Cystic fibrosis
    --Hemophilia A
    --Other (specify)
• Susceptibility to disease:
    --Malignant neoplasm (specify type)
    --Multiple endocrine neoplasia
    --Other (specify)