Orthopedic Coding Alert

Question: What diagnostic code do I use for the loss of reduction or fixation on a fracture when the patient is returned to the operating room?

Georgia Subscriber

 
Answer: Use the same diagnosis as was used for the first reduction, as your physician is still treating the fracture, and append modifier -78 (return to the operating room for a related procedure during the postoperative period) to the code for the operative procedure. If the loss of reduction is due to failure of an internal fixation device implanted at the first surgery, then use the ICD-9 code that describes this complication such as 996.4 (mechanical complication of internal orthopedic device, implant or graft).