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Thread: Currettage with removal of hardware

  1. #1
    Join Date
    Apr 2007
    Columbus, Ohio

    Question Currettage with removal of hardware

    AAPC: Back to School
    Good Day Coders, I just need to run this by someone. The patient had a crushing injury to the foot and the surgeon is removing external fixation prior to doing an OTIF of the distal tibia.He did the original reduction with the external fixator. He coded 20680 for 4 sites: tibia, calcaneus, first metarsal and fifth metarsal. He also coded curettage on each site he removed hardware. There's no mention of any infection. Would the curettage be inclusive of the 20680 or is this something I can bill separately for all four sites? He used 28104 which is for a bone cyst or tumor. I think he was just cleaning the sites really well before he did the fracture. Any Ideas? I can post the notes if needed. Thanks, Paula

  2. #2
    Join Date
    Apr 2007


    can you post the op note pleae

  3. #3
    Join Date
    Apr 2007
    Columbus, Ohio

    Default op note posted

    Here's the op note:

    1. Left distal tibial pelon fracture, closed, intra-articular,
    2. Status post external fixation, left lower extremity.
    3. Late complications of trauma, left lower extremity.
    1. Left distal tibial pelon fracture, closed, intra-articular,
    2. Status post external fixation, left lower extremity.
    3. Late complications of trauma, left lower extremity.
    1. Open treatment, left distal tibial pelon fracture with internal
    fixation, (27827).
    2. Removal of deep hardware, left tibia, (20680).
    3. Removal of deep hardware, left calcaneus, (20680).
    4. Removal of deep hardware, left first metatarsal, (20680).
    5. Removal of deep hardware, left fifth metatarsal, (20680).
    6. Curettage, left tibia, (27635).
    7. Curettage, left calcaneus, (28180).
    8. Curettage, left worse first metatarsal, (28104).
    9. Curettage, left fifth metatarsal, (28104).
    10. Vitagel soft tissue autograft insertion, left ankle wound (20926).
    Stable to the Post Anesthesia Care Unit.
    The patient is a 35-year-old male who was seen previously with a
    work-related injury. He was pinned against the machine and a wall. He
    had an open grade 1 distal fibula fracture and a distal tibial patella
    fracture. These were displaced. Due to the open nature of the injury,
    he was taken emergently for surgery of the ankle. The lateral ankle
    wound had an irrigation and debridement with a formal ORIF of the
    distal fibula. The wound was very clean. The wound looked very good in
    the office recently. There were no signs of infection. He has been
    healing well. We did place on external fixator of the left lower
    extremity, reducing the distal tibia. A CT scan was taken. There was
    intra-articular extension with 3 main fragments of the distal tibia.
    This was satisfactorily reduced with external fixation. It has been
    over a week and the patient's pain and swelling has decreased
    significantly. We did schedule him for a formal removal of hardware, as
    well as ORIF the left distal tibial pelon. The risks and benefits,
    complications were reviewed, and appropriate consent was obtained. The
    patient want to proceed with surgery.
    The patient was seen in the preoperative holding by the department of
    orthopedics and anesthesia, at which time we identified the left lower
    extremity as the appropriate extremity for the procedure. I placed my
    initials on the extremity for identification. He was given IV
    antibiotics preoperatively for prophylaxis. He refused a preoperative
    block by anesthesia. He was taken back to the OR suite, and placed
    supine on a well-padded table. He was placed under general anesthesia
    without complication. A well-padded tourniquet was placed on the left
    upper thigh. The external fixator was removed first from the tibia
    using the wrenches and undoing the clamps from the Stryker-Hoffman
    frame. Next, the pin through the calcaneus was removed deeply from bone
    using a T-handled chuck after cutting the pin on 1 side of the
    calcaneus. Next, a T handle was used to remove the hardware from the
    first metatarsal with the T-handled chuck. The deep hardware from the
    5th metatarsal was then removed again with a T-handled chuck. Once the
    hardware was removed, the extremity was sterilely prepped and draped in
    the normal fashion. I did place separate drapes over the leg and
    curetted out deeply, the tibia first and then the calcaneus, and then
    the 5th and 1st metatarsals. These were curetted out and then irrigated
    out extensively. I then placed Ioban over these holes to not
    contaminate the distal tibial level open reduction and internal
    fixation. Once these were cleaned and covered, the drapes were removed
    and the new drapes were placed over the leg. The leg was elevated, and
    the tourniquet was inflated to 350 mmHg. A skin incision was made over
    the medial malleolus. Blunt dissection was taken up to the medial
    aspect of the distal tibia. A short distal tibial locking plate by
    Synthes was placed up the medial malleolus and the tibial shaft. A pin
    was placed distally through the plate as well as proximally. The plate
    was used to reduce the fracture. This was viewed under fluoroscopy and
    felt to be adequate. There was a fracture also between the anterior and
    posterior tibial articular surfaces. A clamp was placed on these
    articular fragments holding them together. One screw was placed through
    the plate distally with a 3.5 fully-threaded cortical screw, compressing
    the medial and lateral fracture fragments. This was done in the lag
    manner over drilling the proximal cortex. Another cortical screw was
    placed proximally pulling plate to the shaft. I did make a small
    incision of the skin and a 3.5 fully-threaded cancellous screw to obtain
    a good bite was placed through the anterior and posterior fragments
    articular surface in a compressive manner. Blunt dissection was taken
    down to bone and then the 2.5-mm drill was used and the appropriate
    length screw was placed in. The proximal cortex was over reamed for
    compression. This held this piece nicely. Again, fluoroscopy was used
    and the reduction was satisfactory with good position of the hardware.
    I then filled the remaining screws with locking screws using the guides
    and then drilling, and measuring the appropriate size length. Once this
    was completed, the pins were removed. Final x-rays were taken. There
    was satisfactory alignment of the distal tibia with good position of
    hardware. The wound was copiously irrigated out with normal saline.
    The deep tissue was closed with 0 Vicryl. The superficial tissue was
    closed with 2-0 Vicryl and staples were placed on the skin. Local
    anesthetic was injected. The Vitagel soft tissue autograft processed
    with the patient's blood for postoperative hemostasis and potential
    healing was injected deeply. Sterile dressing was applied as well as a
    posterior splint with a sugar-tong. The tourniquet was released, and
    the patient awakened from anesthesia without complication and
    transferred to the Post Anesthesia Care Unit in stable condition.

  4. #4
    Join Date
    Apr 2007
    Columbus, Ohio


    Hello coders, anyone have any ideas on this surgery since I posted the op notes? thanks, Paula

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