Name of the Condition

• Foreign Body in Uterus, Initial Encounter
• Medical Term: T19.3XXA

Summary

• Foreign body in the uterus refers to the presence of an object inside the uterus that is not naturally occurring, which can cause irritation or injury. This code specifies the initial encounter with a healthcare provider for this issue.

Causes

• Possible causes include the insertion of foreign objects for contraceptive purposes (like an intrauterine device), retained products of conception, or accidental placement of non-medical items.

Risk Factors

• Use of intrauterine devices (IUDs) or internal contraceptive devices.
• Recent gynecological procedures or childbirth.
• Participation in non-medical insertion of objects.

Symptoms

• Pelvic pain or discomfort.
• Irregular vaginal bleeding.
• Infection signs such as fever or unusual discharge.

Diagnosis

• Physical and pelvic examination by a healthcare provider.
• Ultrasound imaging or X-rays to locate and identify the foreign body.
• Hysteroscopy for direct visualization.

Treatment Options

• Removal of the foreign object, typically through a minimally invasive procedure like hysteroscopy.
• Antibiotics if an infection is present.
• In severe cases, surgical intervention may be required.

Prognosis and Follow-Up

• Once removed, most patients recover fully without long-term complications.
• Follow-up appointments are crucial to ensure proper healing and to monitor for signs of infection or complications.

Complications

• Ongoing pelvic pain or continuous bleeding.
• Infection that might spread if not treated promptly.
• Potential damage to the uterine lining if left untreated.

Lifestyle & Prevention

• Use medical devices like IUDs under professional guidance.
• Avoid inserting non-medical objects into the uterus.
• Regular gynecological check-ups to ensure devices remain properly placed.

When to Seek Professional Help

• If experiencing severe pain, heavy bleeding, or fever after insertion of an IUD or after any uterine procedure.
• Unexpected or unexplained pelvic discomfort or discharge.

Additional Resources

• American College of Obstetricians and Gynecologists (ACOG)
• Office on Women’s Health

Tips for Medical Coders

• Ensure the encounter is coded as 'initial' to reflect that this is the first interaction regarding this issue.
• Verify patient history to substantiate the presence of a uterine foreign body and avoid coding errors related to prior encounters.