kamer330
Contributor
I need help in coding this surgery. The patient had an initial surgery on 7/6/2018 for open treatment of proximal humeral fracture 23615. Five months later, after global period, she had another surgery by the same surgeon. The procedure performed was hardware removal of multiple screws with irrigation and debridement and revision fixation of greater tuberosity. The OP report states the following: The wound was irrigated thoroughly with antibiotic irrigation and no further purulent or caseous material was encountered. Abundant scar tissue was encountered and careful dissection was completed of the pectoralis from the more proximal plate. Portions of the plate were included or surrounding tissue and anterior screws were removed with fluoroscopic images confirming removal and no further penetration of hardware. The greater tuberosity was found to be slightly rotated around posteriorly and as a result, we reflected this using an elevator. A 2-0 FiberWire suture was woven into the supraspinatus, which was brought around through the plate and secured to the plate with suture. No new screws were placed. The wound was again irrigated thoroughly with normal saline and the interval closed with Vicryl suture in an interrupted fashion. There is a debate in the office if it should be coded 20680 hardware removal and 24999 unlisted for the revision or 23615. Any thoughts would be appreciated. thank you.