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Initial vs subsequent - I'm still a little confused about

C

Ccgerson

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Phoenixville, PA
I'm still a little confused about initial/subsequent encounters for fracture care. Example:

Pt had ORIF one year ago for Right bicondylar tibial fracture. Pt is having removal of hardware due to pain. These are codes I'm looking at:

CPT: 20680-RT
ICD-10: T84.84XA
S82.141D
 
You are treating the complication not the fracture. So unless the fracture has a malunion, non union, or delayed healing, then I assume it has healed. You code only the complication with the initial encounter character as this is the patient's initial encounter for active treatment of the complication.
 
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