Hello coders, the surgeon removed a screw from a wrist fracture about a week after surgery and then put another one back in a different location. I have attached the note but my question is: Do I recode the fracture care? The original surgery was 25609. Do I use 20680 and then use the same code with a modifier? What do you all think? Thanks, Paula
1. Left distal radius removal of deep hardware.
2. Left distal radius insertion of screw.
DESCRIPTION OF PROCEDURE
She was placed under general anesthesia without complication.
The left upper extremity was then placed on a well-padded arm table. The
extremity was sterilely prepped and draped in normal fashion. The old suture
from prior incision was removed. The wound was opened up. Blunt retractors
were placed in the wound. The screw through the plate into the radial styloid
which was prominent was removed. I did feel the track of the screw with a
depth gauge. I also measured this. It appeared that the screw was barely
penetrating the radial carpal joint. I do feel that if the fracture would
have settled more than it would have been more prominent. I redirected the
drill and drilled away from the joint into the radial styloid radially. I
placed an 18 mm multidirectional screw in that engaged the plate in a locking
manner. I checked multiple views under fluoroscopy and there was no screw or
peg penetrating the joint. They were well away from the joint. There was
good reduction of the fracture with good position of the hardware. The wound
was copiously irrigated out with normal saline. The skin was approximated
with 3-0 Vicryl and a running 4-0 intradermal Vicryl was placed. The suture
was buried. Steri-Strips and Mastisol were applied. A sterile dressing was
applied as well as the patient's brace placed back on her. The patient was
then awoken from anesthesia without complication and transferred to the post
anesthesia care unit in stable condition.
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