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2nd request-hardware removal

  1. #1
    Question 2nd request-hardware removal
    Medical Coding Books
    My physician removed hardware from an ankle by 2 seperate incisions of which I know I can only use 20680 once but he also wants to charge for exploration of the tib post tendon, op note states...

    I extended the incision distally from the tib post tendonn and passed a hemostat up the sheath and identified it more proximally where the plate had been close to it. There was some minor abrasion involoving 5-10% of the tendon but the great majority of it was intact. I debided this small area and then thoroughly irrigated, clodes the subcu....

    I looking at this a debridment that had to do with the hardware so it would be bundled. Can he charge for this and if so I have no idea as to what code I would be looking for. Thanks

  2. #2
    so he made 2 seperate incisions and removed hardware twice? was it like a bimalleolar fx? if he made 2 seperate incisions and removed different hardware from both incisions i have always been told you can bill it.

  3. #3
    I agree with previous post..

    If removal of im nail and screws through multipile incisions may be made to remove screws and plate 20680 x 1

    but if pt has tibial plateau and tibial shaft fracture, 20680 may be reported twice because the fractures are:

    1. Non-continguous and
    2. Were fixed with 2 separate plating systems..

    Add modifer 22 to cpt if there is documentation of extraordinary amount of work, or unusual effort in the removal of the hardware.

    Hope this helps...

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