# Attempted Hardware removal



## DRocole72 (Jul 23, 2012)

Need Help!!!!! PAtient was broght in for a syndesmotic screw removal. Op not reads:

Preoperative Diagnosis: Retained syndesmotic screw

Postoperative Diagnosis: Insufficient syndesmotic ligament healing.

Procedure Performed: Attempted removal of syndesmotic screw with reinsertion

Body of Op report: 

Blunt dissection was carried out down to the screw head and I put a screwdriver on it and backed it out so it was only in the fibula. I checked the mortise for stability and it was relatively unstable; I could shift the talus. So, at this point I put the ankle in neutral and I put the screw back in and tightened it up and then rechecked it for stability again, and it was stable at this oint so I felt the patient needed to have the screw in place. 

Then the Dr closed. 

Any Suggestions???????


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## salCCS (Jul 23, 2012)

you will use unlisted code 

78.57/27899


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## DRocole72 (Jul 24, 2012)

That is what I was leaning to myself. Thanks


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## salCCS (Jul 24, 2012)

no problem


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## CVelez (Jul 25, 2012)

I think the code should be 20680 removal of implant deep with appropriate modifier.  If coding for facility that would be 74.

Charla


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## salCCS (Jul 26, 2012)

using encoder

reinsertion fixation device
 - no mention of fracture (prophylactic treatment)
   - specified bone
     - fibula
       - CPT 27899


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