# CPT 20694 with ORIF



## sflorence4695 (Dec 4, 2018)

I am looking for research resources. I review claims, and frequently see Orthopedic providers submitting CPT 20694 (removal of external fixation device, requiring general anesthesia) with an ORIF. I have performed exhaustive searches through my coding manual, the NCCI manual, AAOS Code-X, and Google to find any vetted research indicating whether or not this can be separately reported with an open definitive treatment code. The closest I have is this entry from the NCCI Manual regarding the removal of internal hardware at the same site as a surgical procedure, but I'm looking for something more specific:

National Correct Coding Initiative Policy Manual for Medicare Services

CHAPTER IV SURGERY: MUSCULOSKELETAL SYSTEM

G. Fractures, Dislocations, and Casting/Splinting/Strapping

10. There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable. 

Similarly, if a superficial or deep implant (e.g., buried wire, pin, rod) requires surgical removal (CPT codes 20670 and 20680), it is not separately reportable if it is performed as an integral part of another procedure.

I'm really looking for a cited/vetted resource rather than interpretation or a clinical practice. Thanks!


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## Orthocoderpgu (Dec 4, 2018)

*Don't think that an external fixation device is equal to an implant*

I code for an excellent foot and ankle specialist and see this all the time. The removal of an external fixation device is never going to be bundled with another surgical procedure. For what is done here an external fixation device is placed to hold the foot and or ankle in place for a couple of weeks while the swelling of the tissues goes down. Frequently the restorative procedures will need to be put on hold until there is no longer swelling. Placing it and removing it will never be bundled into another procedure.

After the swelling has gone down, then the surgeon can perform the procedures after taking the external fixator off.

An implant is totally different. That's hardware that has already been used to hold tissue down internally. Most of the time removing this is bundled if another procedure is performed in the same area.

When you are reviewing something with an external fixator, you would never look to bundle it with another procedure.

Looking at if from an ORIF viewpoint, external fixation is never included with ORIF, only INTERNAL fixation. The external fixation will hold the fracture while it heals. Depending on the fracture and location, the internal fixation may never come out, or only come out if there are complications.


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## MI_CODER (Dec 5, 2018)

I agree with Orthocoderpgu. I also see this all the time and have never run into any issues with 20694 being bundled with any ORIF codes. I always double check though and run the codes through a CCI edit checker just to make sure.

Not sure if this might help but I found this:

CPT Assistant, January 2018 Page: 3 Category: Fracture and dislocation restorative services

Removal of External Fixation (Hardware)

When a fracture is stable or sufficiently healed, an external fixation system may no longer be needed and is typically removed. CPT codes 20690-20697 relate to the application, adjustment, and removal of an external fixation system. Code 20694, Removal, under anesthesia, of external fixation system, would be appropriately reported only when anesthesia is required to perform the removal of the external fixator system. Removal of the external fixator performed without anesthesia is not a separately reportable procedure because local infiltration of medication(s), anesthetic, or contrast agent before, during, or at the conclusion of the procedure is an inclusive service of codes 20670, 20680, and 20690, and is not considered "under anesthesia."


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## sflorence4695 (Dec 5, 2018)

*Thank you!*

Thank you for the replies. That makes sense. The challenge is that I only have a limited view (surgeon's OR claim), so there's no way to know when/who placed it. I did see the CPT Assistant article, but it doesn't quite fit with this situation, since it states that the removal frequently takes place after the fracture is healed and external fixation is no longer needed, which is not the case I deal with. 

Orthocoderpgu-do you by chance have any resources I could cite/review to support your reply? Or, can you recommend a resource (beyond CPT, NCCI, AAOS and/or Karen Zupko) that could provide some research?


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## Orthocoderpgu (Dec 6, 2018)

*I don't know of any resource but keep this is mind...*

Restorative procedures can bundle. The application of an external fixator is NOT a restorative procedure, it's meant to hold the limb in place for a period of time.  So either putting on or taking off this device would never be bundled since its not a restorative procedure, like performing ORIF of an ankle fracture.


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