Pin removal in the office status post mallet pinning


North Andover, MA
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Hi All, hope someone will help with this.

Physician wants to billed for pin remova in the officel after mallet pinning in the OR.
I believe we should only bill if you need to go back to the OR for removal. Here is the procedure note.

Status post left long finger mallet pinning.

Date of Surgery: 10/17/2016.

Disposition: Pin removal and followup as needed.

Interval History: doing excellent. She has minimal pain and discomfort. She is ready to have the pin removed.

Examination of the left long finger shows the skin is intact. The pin site is clean. The pin is very beneath the skin. The finger is well aligned. There is no evidence of infection. Neurovascularly intact. A 2+ radial pulse. Less than 2-second capillary refill.

Imaging: AP and lateral views of the left long finger obtained today show surgical hardware to be in appropriate anatomical position. No evidence of loosening or osteal lucency.

Assessment and Plan: We discussed today's clinical findings as well as treatment options moving forward. At this point, is ready to have the pin removed. This was done in the office under sterile technique without any complications. Dressing was placed over the pin site. Local wound care advice given and discussed with her that followup at this point can be as needed.


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I would have to agree the only way to bill the pin removal would be in the or. the removal in the office is part of the global package .