Attempted Hardware removal

DRocole72

Contributor
Messages
12
Location
Mishawaka, IN
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0
Need Help!!!!! PAtient was broght in for a syndesmotic screw removal. Op not reads:

Preoperative Diagnosis: Retained syndesmotic screw

Postoperative Diagnosis: Insufficient syndesmotic ligament healing.

Procedure Performed: Attempted removal of syndesmotic screw with reinsertion

Body of Op report:

Blunt dissection was carried out down to the screw head and I put a screwdriver on it and backed it out so it was only in the fibula. I checked the mortise for stability and it was relatively unstable; I could shift the talus. So, at this point I put the ankle in neutral and I put the screw back in and tightened it up and then rechecked it for stability again, and it was stable at this oint so I felt the patient needed to have the screw in place.

Then the Dr closed.

Any Suggestions???????
 

CVelez

Networker
Messages
91
Location
Sarasota
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I think the code should be 20680 removal of implant deep with appropriate modifier. If coding for facility that would be 74.

Charla
 

salCCS

Networker
Messages
98
Location
Hollywood, CA
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using encoder

reinsertion fixation device
- no mention of fracture (prophylactic treatment)
- specified bone
- fibula
- CPT 27899
 
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