Orthopedic Coding Alert

Question: A patient had a repeat ORIF (open reduction internal fracture) of a clavicle fracture because the lateral aspect of the plate disengaged from the lateral clavicle, resulting in loss of fixation of the hardware. Our surgeon removed the old hardware and replaced it with new hardware. The repeat procedure happened within the global period. What diagnosis and procedure codes should I report?

Arkansas Subscriber

Answer: Code the surgery with 23515 (Open treatment of clavicular fracture, includes internal fixation, when performed). Hardware removal is bundled into the procedure. Because this encounter is related to the original surgery but still within the 90-day global period, append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 23515.

Distinction: If the procedure was unplanned and outside the global period, you would report 23515 without a modifier.

Check the patient's chart to determine the reason for the problem, then submit the appropriate complication diagnosis codes. Two possible options are 996.40 (Unspecified mechanical complication of internal orthopedic device, implant, and graft) or 996.49 (Other mechanical complication of other internal orthopedic device, implant, and graft).