Wiki Attempted Hardware removal


Mishawaka, IN
Best answers
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???????
I think the code should be 20680 removal of implant deep with appropriate modifier. If coding for facility that would be 74.

using encoder

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