Crystal's MCW Coder Hub🧬 ICD-10-CM H02.811 — Retained Foreign Body in Right Upper Eyelid
Overview
ICD-10-CM H02.811 classifies a retained (embedded) foreign body lodged within the tissue of the right upper eyelid. This is distinct from a superficial or conjunctival foreign body — the term “retained” indicates that the foreign material has penetrated or become embedded in the eyelid tissue itself and has not been immediately cleared by normal tearing or blinking mechanisms. Common culprits include metallic fragments, wood splinters, glass shards, plant material, projectile debris, and industrial particulates.
Accurate coding of H02.811 is essential for establishing medical necessity for removal procedures, supporting imaging authorization (orbital X-ray or CT to localize radiopaque objects), triggering appropriate infection surveillance (particularly for organic materials such as wood, which carry a high risk of suppurative infection), and ensuring proper documentation of work-related or trauma-related eye injuries for medicolegal and workers’ compensation purposes. The Use Additional Code instruction requires that the type of retained foreign body be identified with a code from the Z18.- category.
Code Breakdown
The structure of H02.811 follows the ICD-10-CM taxonomy:
| Segment | Value | Description |
|---|---|---|
| Category | H02 | Other disorders of eyelid |
| Subcategory | H02.8 | Other specified disorders of eyelid |
| Subgroup | H02.81 | Retained foreign body in eyelid |
| Laterality + Position | 1 | Right upper eyelid |
Full H02.81x Laterality & Position Subcodes
| Code | Description |
|---|---|
| H02.811 | Retained foreign body in right upper eyelid ← YOU ARE HERE |
| H02.812 | Retained foreign body in right lower eyelid |
| H02.813 | Retained foreign body in right eye, unspecified eyelid |
| H02.814 | Retained foreign body in left upper eyelid |
| H02.815 | Retained foreign body in left lower eyelid |
| H02.816 | Retained foreign body in left eye, unspecified eyelid |
| H02.819 | Retained foreign body in unspecified eye, unspecified eyelid |
Laterality and Eyelid Position — Both Required
ICD-10-CM requires specification of both laterality (right vs. left) AND eyelid position (upper vs. lower) for H02.81x codes. When the medical record clearly documents “right upper eyelid,” H02.811 is the correct code. Do not default to H02.813 (right eye, unspecified eyelid) or H02.819 (unspecified eye, unspecified eyelid) when the documentation supports greater specificity. Query the provider for eyelid position when only laterality is documented but upper vs. lower is not specified.
Coding Guidelines
Includes
- Embedded foreign body in the soft tissue of the right upper eyelid
- Metallic, non-metallic, organic, or inorganic material retained within right upper eyelid tissue
- Foreign body that has penetrated the eyelid skin or palpebral conjunctival surface and is no longer on the surface
Excludes1 — Mutually Exclusive; Cannot Code Together With H02.811
- Laceration of eyelid with foreign body (S01.12-) — when the primary presentation is an active traumatic laceration of the eyelid with an embedded foreign body, code from the injury chapter (S01.12-) rather than H02.811; H02.811 is appropriate for retained (chronic/subacute) foreign bodies discovered after the initial injury
- Retained intraocular foreign body (H44.6-, H44.7-) — if the foreign body is within the globe itself (anterior or posterior segment), code from H44.6x or H44.7x; H02.811 applies only to foreign bodies within the eyelid tissue, not the eye itself
- Superficial foreign body of eyelid and periocular area (S00.25-) — superficial FB on the surface of the eyelid without penetration is coded from the injury chapter; H02.811 is reserved for embedded/retained material within the tissue
Use Additional Codes
H02.811 carries a “Use additional code” instruction — the type of retained foreign body must be identified with a code from the Z18.- category:
| Z18 Code | Foreign Body Type | Common Clinical Context |
|---|---|---|
| Z18.01 | Retained depleted uranium fragments | Military/combat; industrial uranium exposure |
| Z18.09 | Other retained radioactive fragments | Radiation therapy seeds; other radioactive materials |
| Z18.10 | Retained metal fragments, unspecified | Generic metal debris; industrial or construction injuries |
| Z18.11 | Retained magnetic metal fragments | Ferrous metal; amenable to magnet-assisted removal |
| Z18.12 | Retained nonmagnetic metal fragments | Stainless steel, aluminum, copper; cannot use magnetic removal |
| Z18.2 | Retained plastic fragments | Plastic debris, recreational or industrial |
| Z18.31 | Retained animal quills or spines | Porcupine quills, sea urchin spines, plant thorns |
| Z18.32 | Retained tooth | Dental fragment post-trauma |
| Z18.33 | Retained wood fragments | High infection risk; organic material; commonly suppurative |
| Z18.39 | Other retained organic fragments | Vegetative matter, insect parts, other organic material |
| Z18.81 | Retained glass fragments | Glass; may be radiolucent on plain X-ray; CT preferred |
| Z18.83 | Retained stone or crystalline fragments | Gravel, stone, concrete debris |
| Z18.89 | Other specified retained foreign body fragments | Rubber, foam, synthetic materials not elsewhere classified |
| Z18.9 | Retained foreign body fragments, unspecified | Use only when type cannot be determined |
Z18 Code Is Not Optional
The “Use additional code” convention in ICD-10-CM for H02.811 is an instructional notation, and including the Z18 code is considered a best practice for complete coding. The type of foreign body material has direct clinical significance — organic materials (wood: Z18.33) carry a high risk of suppurative infection requiring aggressive treatment, while magnetic metal fragments (Z18.11) may be amenable to non-surgical magnet-assisted removal. Payers and auditors reviewing claims for foreign body removal procedures will expect to see both H02.811 and the appropriate Z18 code on the claim.
Code Tree
Chapter 7: Diseases of the Eye and Adnexa (H00-H59)
└── Disorders of eyelid, lacrimal system and orbit (H00-H05)
└── Other disorders of eyelid (H02)
└── Other specified disorders of eyelid (H02.8)
└── Retained foreign body in eyelid (H02.81)
├── H02.811 — Retained foreign body in right upper eyelid ← YOU ARE HERE
├── H02.812 — Retained foreign body in right lower eyelid
├── H02.813 — Retained foreign body in right eye, unspecified eyelid
├── H02.814 — Retained foreign body in left upper eyelid
├── H02.815 — Retained foreign body in left lower eyelid
├── H02.816 — Retained foreign body in left eye, unspecified eyelid
└── H02.819 — Retained foreign body in unspecified eye, unspecified eyelidRisk Adjustment (HCC)
Hierarchical Condition Category (HCC) status determines impact on risk adjustment scores for Medicare Advantage and ACA plans.
- HCC Status: No — H02.811 does not map to a CMS-HCC v28 category
- RAF Impact: This code does not contribute to the Risk Adjustment Factor (RAF) score under the current CMS-HCC v28 model
- Clinical Relevance: While not an HCC, retained eyelid foreign bodies in Medicare-aged patients may indicate underlying occupational exposure history, prior trauma, or complicating systemic conditions (eg, diabetes, immunosuppression) that do carry HCC weight and should be coded when documented alongside H02.811
Inpatient Impact (MS-DRG)
In the inpatient setting, H02.811 influences MS-DRG assignment.
- CC/MCC Status: Non-CC — H02.811 does not carry CC or MCC weight under CMS MS-DRG v42
- Impact: This code does not independently shift a DRG to a higher severity tier. Inpatient admission for isolated retained eyelid foreign body is rare; when it does occur (eg, complex embedded organic foreign body with orbital cellulitis, systemic infection, or need for general anesthesia), the complicating secondary diagnoses (orbital cellulitis, septicemia, abscess) will drive DRG and CC/MCC capture
- POA Indicator: Present on Admission (POA) reporting is required for all inpatient diagnoses; for retained foreign bodies, POA = Y when the FB was present prior to or at the time of admission
MS-DRG for Retained Eyelid FB With Complications
When H02.811 is associated with orbital cellulitis (H05.011-H05.013), eyelid abscess (H00.011-H00.016), or septicemia, the infection or sepsis codes will drive DRG assignment. A retained organic foreign body (wood: Z18.33) with documented suppurative infection may generate a significantly higher-weighted DRG than the foreign body code alone. Always code all documented complications to accurately reflect the severity of the admission.
Common CPT Pairings
Foreign Body Removal Procedures
| CPT Code | Description | When Used With H02.811 |
|---|---|---|
| 67938 | Removal of embedded foreign body, eyelid | Primary procedure code for removal of a foreign body that has penetrated and is embedded within eyelid tissue; the most specific match for H02.811 |
| 65205 | Removal of foreign body, external eye; conjunctival superficial | Use when FB is on the conjunctival surface only — not embedded in eyelid tissue; less specific than 67938 for true H02.811 presentations |
| 65210 | Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival | When the FB is subconjunctival or embedded in conjunctiva — differentiate from eyelid tissue involvement |
| 65220 | Removal of foreign body, external eye; corneal, without slit lamp | Corneal FB — different anatomic site; not paired with H02.811 unless concurrent corneal involvement is documented |
| 65222 | Removal of foreign body, external eye; corneal, with slit lamp | Corneal FB with slit lamp — separately reportable if corneal FB also present alongside retained eyelid FB |
Imaging — Foreign Body Localization
| CPT Code | Description | When Used With H02.811 |
|---|---|---|
| 70030 | X-ray, eye, for detection of foreign body | Initial imaging for radiopaque metallic foreign bodies; limited utility for wood, glass, or plastic |
| 70480 | CT scan, orbit, face, and/or fossa; without contrast | Preferred imaging for precise localization, particularly for radiolucent foreign bodies (wood, glass) or when orbital involvement is a concern |
| 70481 | CT scan, orbit, face, and/or fossa; with contrast | When concurrent infection, abscess, or orbital cellulitis requires contrast-enhanced evaluation |
| 76514 | Ophthalmic ultrasound, B-scan and/or standardized A-scan | Ultrasound localization when CT is unavailable or when real-time guidance for removal is needed |
Post-Removal / Wound Management
| CPT Code | Description | When Used With H02.811 |
|---|---|---|
| 67930 | Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; partial-thickness | When eyelid repair is required after foreign body removal |
| 67935 | Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva; full-thickness | Full-thickness eyelid repair post-removal |
| 99213-99215 | Office visit, established patient | Follow-up encounters for wound check, infection surveillance, or removal of sutures post-procedure |
Clinical Coding Examples
Example 1: ED Presentation — Acute Metallic Foreign Body, Right Upper Eyelid
Scenario: A 34-year-old male presents to the ED after being struck in the right eye by a metal fragment while grinding steel without eye protection. Examination reveals a small metallic fragment embedded in the right upper eyelid at the superior tarsal border. Slit lamp confirms no corneal or intraocular involvement. The fragment is removed under direct visualization without incision. Wound is irrigated and dressed.
Coding:
- Primary: H02.811 — Retained foreign body in right upper eyelid
- Secondary: Z18.12 — Retained nonmagnetic metal fragments (steel is non-magnetic)
- CPT: 67938 — Removal of embedded foreign body, eyelid (right)
- Note: If the encounter took place in the ED and an E/M service is documented and separately identifiable beyond the procedure, the appropriate ED E/M code may also be reported with modifier -25 on the E/M.
Example 2: Office Visit — Retained Wood Splinter Discovered Several Days Post-Injury
Scenario: A 52-year-old female presents to an ophthalmology office with a 5-day history of right upper eyelid swelling, erythema, and tenderness. She recalls a wood splinter striking her eye while gardening. Examination reveals a 4mm wood fragment embedded in the right upper eyelid with surrounding cellulitis. CT orbit confirms no intraorbital extension. Fragment removed surgically under local anesthesia.
Coding:
- Primary: H02.811 — Retained foreign body in right upper eyelid
- Secondary: Z18.33 — Retained wood fragments (high infection risk; organic material)
- Secondary: H00.011 — Hordeolum externum / preseptal cellulitis, right upper eyelid — or appropriate eyelid cellulitis/abscess code if cellulitis is separately documented
- CPT: 67938 — Removal of embedded foreign body, eyelid
- Note: Organic foreign bodies (wood: Z18.33) carry a significantly higher suppuration and infection risk than metallic fragments. The Z18 code here directly informs clinical decision-making — broader antibiotic coverage and closer wound surveillance are standard for retained organic FB. Coding it completely supports medical necessity for the antibiotic prescriptions and follow-up visit frequency.
Example 3: Retained FB Confirmed on Imaging — Incidental Discovery
Scenario: A 67-year-old male presenting for routine blepharoplasty evaluation is found on pre-op CT orbit to have a small retained glass fragment in the right upper eyelid from a motor vehicle accident 15 years prior. The fragment is asymptomatic and not palpable. The surgeon documents the finding and plans elective removal at the time of blepharoplasty.
Coding:
- Diagnosis 1: H02.811 — Retained foreign body in right upper eyelid
- Diagnosis 2: Z18.81 — Retained glass fragments
- Note: Even when the retained FB is asymptomatic and incidentally discovered, it is appropriately coded when it is documented and affects management (eg, adding foreign body removal to the surgical plan). The Z18.81 glass code is important here — glass may not appear on plain X-ray and CT was required for detection, supporting the imaging authorization and the plan for removal.
Example 4: Wrong Site — Ruling Out H02.811
Scenario: A patient presents with a metallic foreign body on the surface of the right upper eyelid skin (not penetrating into the tissue) following an industrial spray injury. The fragment is wiped away with irrigation and a cotton swab. No embedding confirmed.
Coding:
- Do NOT use H02.811 here. A superficial (non-embedded) foreign body on the surface of the eyelid or periocular area is coded from the injury chapter: S00.251 (superficial foreign body of right eyelid and periocular area). H02.811 is reserved for foreign bodies that are retained within the eyelid tissue — not surface-level.
Revenue Cycle Considerations
- wRVU: Not applicable — ICD-10-CM diagnosis codes do not carry wRVUs; procedure codes (67938, 65205, 65210) carry the wRVU value for the clinical encounter
- Assistant Payable: Not applicable — this attribute applies to surgical CPT codes
- Denial Risk: Moderate to High. Claims for 67938 (embedded eyelid foreign body removal) paired with H02.811 may be scrutinized when documentation does not clearly distinguish embedded vs. superficial foreign body. Payers may attempt to downcode to 65205 (superficial conjunctival FB removal, lower reimbursement) if the operative note does not explicitly describe penetration into eyelid tissue. The operative note must clearly document: (1) depth of FB, (2) method of removal (eg, incision vs. direct extraction), and (3) eyelid tissue involvement
- Workers’ Compensation / Occupational Medicine: Many retained eyelid foreign bodies occur in occupational settings (metal grinding, woodworking, construction). Workers’ comp claims require documentation of the work-related mechanism of injury and may require additional claim forms. The Z18 code identifying material type is particularly important in workers’ comp settings
- Prior Authorization: CT orbit or MRI orbit for FB localization may require prior authorization, particularly for non-acute (chronic/incidentally discovered) retained foreign bodies. The H02.811 + Z18 code combination supports the imaging authorization request
- Imaging Caution — MRI Contraindication: Metallic retained foreign bodies in or near the orbit are a relative to absolute contraindication for MRI, depending on material composition. When Z18.11 or Z18.12 (retained magnetic or nonmagnetic metal) is documented near the orbit or eye, MRI ordering must be flagged and cleared by the ophthalmologist. This is a patient safety issue with direct coding and documentation implications
Related Codes
- H02.812: Retained foreign body in right lower eyelid
- H02.813: Retained foreign body in right eye, unspecified eyelid
- H02.814: Retained foreign body in left upper eyelid
- H02.815: Retained foreign body in left lower eyelid
- H02.816: Retained foreign body in left eye, unspecified eyelid
- H02.819: Retained foreign body in unspecified eye, unspecified eyelid
- H44.6-: Retained (old) intraocular foreign body, magnetic — use instead of H02.811 if FB is within the globe
- H44.7-: Retained (old) intraocular foreign body, nonmagnetic — use instead of H02.811 if FB is within the globe
- S01.12-: Laceration of eyelid with foreign body — use instead of H02.811 for acute traumatic laceration with FB
- S00.25-: Superficial foreign body of eyelid and periocular area — use instead of H02.811 for non-embedded surface FB
- Z18.-: Retained foreign body type — always report alongside H02.811
Clinical Management Notes
Management of H02.811 depends on foreign body type, depth, and presence of infection:
- Removal: 67938 (embedded eyelid foreign body removal) is the standard procedure; technique varies from direct extraction under slit lamp/loupe magnification to small incision with forceps for deeply embedded material
- Imaging prior to removal: Plain X-ray (70030) for metallic FB; CT orbit (70480/70481) for radiolucent materials (wood, glass, plastic) or when orbital extension is a concern
- Antibiotic therapy: Oral antibiotics (eg, amoxicillin-clavulanate) for organic FB (Z18.33) or any retained FB with surrounding cellulitis; IV antibiotics for preseptal or orbital cellulitis with systemic involvement
- MRI safety screening: Mandatory for all retained metallic FB cases prior to any MRI imaging of the head/orbit; coordinate with ordering provider
- Tetanus prophylaxis: Verify immunization status for all penetrating eyelid injuries; administer Td booster or TIG as indicated per ACIP guidelines
- Follow-up: Wound check at 48-72 hours for organic FB removals; ophthalmology follow-up at 1-2 weeks for wound healing and infection clearance assessment
ICD-10-CM Official Guidelines for Coding and Reporting FY2025 CMS ICD-10-CM Tabular List FY2025 CMS MS-DRG Grouper v42 (FY2025) CMS-HCC Risk Adjustment Model v28 (2024) NIH VSAC ICD-10-CM Code Browser — H02.811 (2023) AAPC ICD-10-CM Code Reference — H02.811, H02.81 AMA CPT 2025 Professional Edition (CPT 67938, 65205, 65210, 70030, 70480) American Academy of Ophthalmology — Preferred Practice Pattern: Ocular Foreign Bodies Optum ICD-10-CM Expert for Physicians 2025