How would you code this? Any guidance appreciated!

PRE-OP DIAGNOSIS: Painful hardware left hip

HPI: Had a left gamma nail placed. The fracture healed with compression and the screw slid laterally. This became painful. She has a hard time laying on that side and has pain with walking.


PROCEDURE IN DETAIL: After informed consent was obtained the patient was taken to the operating room and placed in a lateral decubitus position all bony prominences were well padded and the left hip was then prepped and draped in normal sterile fashion.

The previous incision was made laterally and the dissection was carried down to the blade. A guidewire was placed into the screw and a curette was used to remove tissue from the lateral aspect of the screw. This point screwdriver was then locked into the screw. This could not be removed because the setscrew was then placed. Therefore the proximal incision was made and a guidewire was placed to the proximal nail and the initial Reamer was used to remove bone proximal to the nail. The flexible screwdriver was then used to loosen the setscrew and at that point the 100 millimeters screw was removed. This was shortened to a 75 screw and this was placed into position position. This was done under C-arm and found to be in good position. This was checked on the AP and lateral views. The wound was then irrigated and closed with 1. Vicryl 2 0 and Monocryl for the subcu Steri-Strips and sterile dressing applied patient awakened taken recovery room stable condition.

IMPLANTS: 75 screw