# Retained hardware



## rjenn86 (Jul 16, 2013)

I'm unsure as what code to use for the retained hardware. The assessment of the dictation reads:  
left peroneal tenosynovitis, possible peroneus brevis tear.
#2 retained hardware of left fibula

I was thinking to use 996.40 but doesnt note complications and the reason for the hardware is from previous fx that was fixed years ago by diff doc. Thank you.


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## mcalonzo2000 (Jul 16, 2013)

V54.01 Encounter for removal of internal fixation device.


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## rjenn86 (Jul 16, 2013)

That's what I was going to use but right now he isnt stating that he will be removing it. Would I still use V54.01? Thank you


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## monica03 (Jul 17, 2013)

rjenn86 said:


> That's what I was going to use but right now he isnt stating that he will be removing it. Would I still use V54.01? Thank you



No you can't use that unless he is removing it.  Is he just stating that it is there?


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## rjenn86 (Jul 17, 2013)

Yes, the impression reads: 

left peroneal tenosynovitis, possible peroneus brevis tear.
#2 retained hardware of left fibula

Xray exam reads:  3 views left ankle obtain the office today reveal ankle mortise remains intact without significant arthrosis.  There is no widening of the syndesmosis.  The there are 3 retained screws in the fibula, the center screw extends approximately 3 mm posteriorly into the peroneal sheath.

Could I use 996.40 from what the xray exam is stating? Thank you


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## jdemar (Jul 18, 2013)

Healed:   traumatic fx V15.51, healed pathological fx V13.51,  healed stress fx V13.52 (listed under persons with potential health hazards related to personal & family hx.


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