Hardware removal
The real issues at hand, or questions to be answered, are whether the fracture has healed and no longer under the status of "Active Treatment," and why/for what reason is the fixation being removed? If still under "Active Treatment," as this person does not appear to be, then there would have to be a reason for removal such as a complication for which a T84.1/2/3/4/6/8_ _ _ would be appropriate along with the Fracture Code and the appropriate 7th character (D, etc.) The history as given for this case implies that the fracture has healed and is no longer under "Active Treatment , which brings up the question as to why the fixation is going to be removed. This brings up the use of Z Codes. Z Codes are not diagnosis codes, in and of themselves, but are reasons for encounters. If the patient is being seen to discuss the hardware removal of a previously well healed fracture without identifiable residual complications or problems, then the Z47.2 code would probably be appropriate, along with Z87.81, Personal History of Healed Traumatic Fracture.
Alan Pechacek, M.D.