Question Coding multiple CPT 20680 or ?

KPriceAZ08

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I have a question regarding the appropriate coding of multiple CPT 20680.
In the case below, the patient had retained wires to his carpal bones and to his metacarpals. A total of 6 K-wire pieces removed. The surgeon also did a wrist fusion with autograft/allograft with hardware placement.


Per AMA CPT Assitant (June 2009) "reporting removal of hardware CPT codes multiple times is indicated only when fixation device(s) are removed from separate fractures at different anatomical sites or for two fractures that are considered noncontiguous on the same bone (such as proximal and distal fracture site."

I am leaning toward coding the 20680 only once since the removal was from the contiguous area of the wrist carpals and metacarpals. I would appreciate another coder's thoughts (any helpful links) regarding this.
Since he did the wrist fusion with hardware placement - would we even code for the pin removal?
Thanks for your help -



POSTOPERATIVE DIAGNOSES:
1. Right wrist painful instability.
2. Right wrist retained deep hardware.

PROCEDURES PERFORMED:
1. Right wrist deep hardware removal of six pins total.
2. Right wrist fusion with autograft and allograft.

ANESTHESIA: Regional block to the right upper extremity and MAC.

SPECIMENS: Six K-wires removed.

COMPLICATIONS: None.

IMPLANTS: Acumed neutral wrist fusion plate and Biomet StaGraft 2 mm.

INDICATIONS FOR PROCEDURE: The patient is a 65-year-old male who initially was treated 1 year ago for a complex right wrist dislocation and open injury, which had surgeries subsequent to that now and continues to have pain with his right wrist with limited range of motion and ulnar deviation to his wrist causing him weakness with grip and grasp. He also has retained wires with initial surgery to his carpal bones and to his metacarpals. Risks, benefits, indications and alternatives to right wrist, removal hardware with wrist fusion with autograft and possible allograft were discussed in detail with the patient. The patient demonstrated full understanding and desired to proceed. Therefore, an informed surgical consent was obtained.
DESCRIPTION OF PROCEDURE: The patient's right wrist was marked in the preoperative area. The patient received the anesthetic regional block to the right upper extremity by the anesthesia staff. The patient was then brought to the operating room, placed supine on the operating room table with the hand table to the right side of the patient. Then, 2 grams of Ancef was given for preoperative antibiotics. The right upper extremity was prepped and draped in usual sterile fashion using ChloraPrep.

After the appropriate surgical time-out was undertaken, the right upper extremity was elevated and exsanguinated with an Esmarch bandage and tourniquet was raised to 250 mmHg. The wrist was first addressed with longitudinal incision centered over the index metacarpal shaft and carried proximally over the wrist just ulnar to the Lister tubercle and proximally over the dorsal distal radius. Skin flaps were raised through scar tissue sharply. Bipolar electrocautery was used for hemostasis. The EPL tendon was released from its compartment and retracted radially. It was intact without injury. The fourth dorsal wrist compartment was also elevated from dorsal wrist and the fourth dorsal wrist compartment tendons were retracted ulnarly. The posterior interosseous nerve was visualized over the floor of the fourth dorsal wrist compartment and approximately 3 cm of this nerve was transected using bipolar electrocautery for PIN neurectomy. The dorsal wrist capsule was elevated in a radial based flap and had a bunion scar tissue. There was normal appearing synovial tissue expressed from the wrist joint itself. Using fluoroscopic guidance, there were six total K-wire pieces which were removed, one was from the lunate and distal radius and one was in the lunate itself, another one was in the capitate from the region of the ring finger metacarpal base, another was between capitate and hamate and last two were from the capitate into the middle finger metacarpal base and lastly from the small finger metacarpal all the way to index metacarpal base. That pin was removed through a separate incision in the hypothenar aspect of the hand. Fluoroscopic views were also then taken to show removal of all retained wires that were deep. There was significant scar tissue and denuded cartilage between the capitate and lunate which was fully debrided as well as between the capitate and hamate. The proximal articular surface remaining in the lunate was debrided off its cartilage surfaces as well as the distal radius.

The cartilage surface between the capitate and the trapezoid as well as the trapezoid and the base of the index metacarpal were all debrided as well. The index metacarpal was subluxed from dorsally and this was debrided with a rongeur to a smooth edge to allow for plate fit. An Acumed neutral wrist fusion plate was then selected and positioned into place first with olive wires into the index metacarpal into the dorsal distal radius to allow for a neutral and slightly radial biased attitude of the wrist joint. Good position was verified appropriate by fluoroscopy. The site of this plate position was then marked with those wire holes and the plate was removed. The articular surfaces that were previously noted to be denuded were packed with Biomet StaGraft 2 mL in total mixed with some autograft which was obtained from the index metacarpal base as well as the dorsal distal wrist after the Lister tubercle had been debrided. The wrist joint in the carpal bones were then manually compressed and the Acumed wrist fusion plate was positioned again. The plate was secured distally with three cortical screws and then proximally with cortical screw in the oblong hole in compression mode. Fluoroscopic views were then taken to verify appropriate wrist position, plate placement and compression to the carpal region and the radiocarpal joint and additional two cortical screws were placed in the shaft as well as an additional fourth cortical screw in the index metacarpal followed by lastly a cortical screw in the carpal row.

Final fluoroscopic views were taken in AP, lateral and oblique planes to verify appropriate hardware position and fusion construct. The wound was irrigated with saline. The wrist capsule had been closed for position underneath the plate rather prior to plate final placement and then it was closed with 3-0 Vicryl suture. The extensor retinaculum was closed over the fourth compartment and the EPL tendon was left transposed subcutaneously radially. The retinaculum was closed with 3-0 Vicryl suture. The skin was closed with 4-0 nylon suture. Dry sterile dressing was applied with Xeroform, fluffs, ABD, Sof-Rol and volar plaster splint.

End of report


Thank you for your help -
Kristen

Kristen Price COC, CPC
Columbus, OH
 
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In this instance you would not bill for the removal of pins.
NCCI states Chapter 4

"CHAP4-CPTcodes20000-29999_final10312018.docx
Revision Date: 1/1/2019
CHAPTER IV
SURGERY: MUSCULOSKELETAL SYSTEM
CPT CODES 20000-29999
FOR
NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL
FOR MEDICARE SERVICES
Current Procedural Terminology (CPT)

"10. There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable." Revision Date (Medicare): 1/1/2019 IV-14
 
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