# Removal of hardware



## trose45116

CAN YOU ONLY CAPTURE THIS ONCE FOR THE 20680??



Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion. 


POSTOPERATIVE DIAGNOSIS:  Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion. 


PROCEDURE:  Removal of hardware, right ankle, from medial malleolus and distal tibia with multiple bone cultures to rule out osteomyelitis.   

ANESTHESIA:  General.  

ESTIMATED BLOOD LOSS:  Minimal. 


TOURNIQUET TIME:  40 minutes.  

COMPLICATIONS:  None. 

SPECIMENS:  Multiple cultures from the right ankle.  



CLINICAL NOTE:  This is a 65-year-old woman who had a bimalleolar right ankle fracture dislocation treated by a doctor in Florida.  She had two operations, one for the initial ORIF, and another for revision ORIF secondary to hardware failure and loss of fixation.  The patient developed postoperative infection and was treated with antibiotics through a PICC line and then with oral antibiotics, and her soft-tissue wounds eventually healed, but she has pain now from prominent hardware.  The medial malleolar screw was backing out, and there are multiple loose screws in the distal fibula as well.  After a lengthy discussion regarding treatment options, it is elected to remove the hardware and perform multiple bone cultures to rule out infected nonunion. Depending on the results of the bone cultures devise more definitive care at a later date.  Informed consent was obtained prior to coming to the operating room. 



DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed supine on the operating room table where general anesthetic was administered by the Anesthesia Department. One gram of Kefzol was administered intravenously.  The tourniquet was placed on the right calf.  The foot was prepped and draped in the usual sterile fashion, exsanguinated with an Esmarch, and the tourniquet inflated to 250 mmHg.  A 2 cm incision was made on the medial aspect of the ankle where the palpable screw in the medial malleolus was encountered very superficially in the ankle.  Dissection was carried out down to the medial malleolar cortex. The screw was removed, and curettes were used to culture the bone tissue.  This material was sent for culture sensitivity as well as histopathology to rule out osteomyelitis.  This wound was copiously irrigated and closed with 4-0 nylon suture.  An incision was then made on the lateral aspect of the ankle using the previous surgical incision from the tip of the fibula proximally about 6 cm and carried down sharply through skin and subcutaneous tissues and fascia and then directly down to the lateral fibular cortex where there was encountered two small fragment plates from a manufacturer not readily recognized, one anteriorly and one laterally.  The multiple screws were loosened and backing out into the soft tissue.  All screws were easily removed, and the plates were removed with an elevator.  Inspection then indicated that there was a fibrous nonunion of the distal fibular fracture as well with gross motion noted upon varus/valgus stress of the ankle.  Soft-tissue debridement was performed, and the wound was copiously irrigated and then closed with 0 Vicryl in the fascia, 2-0 Vicryl in subcutaneous tissues, and surgical skin staples in the skin.  Then, 0.5% plain Marcaine was infiltrated in the incisions for postoperative analgesia, and then the wounds were dressed with Adaptic, dry sterile dressings, and a well-padded, nonweightbearing, short-leg fiberglass cast.  The tourniquet was deflated, and the patient was awakened and transferred to the recovery room in stable condition having tolerated the procedure well


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## jdemar

Two separate bones, 2 times.


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## colham478

You can also code by incisions.


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## PLAIDMAN

trose45116 said:


> CAN YOU ONLY CAPTURE THIS ONCE FOR THE 20680??
> 
> 
> 
> Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion.
> 
> 
> POSTOPERATIVE DIAGNOSIS:  Retained hardware, right ankle with malunion of bimalleolar ankle fracture, rule out infected nonunion.
> 
> 
> PROCEDURE:  Removal of hardware, right ankle, from medial malleolus and distal tibia with multiple bone cultures to rule out osteomyelitis.
> 
> ANESTHESIA:  General.
> 
> ESTIMATED BLOOD LOSS:  Minimal.
> 
> 
> TOURNIQUET TIME:  40 minutes.
> 
> COMPLICATIONS:  None.
> 
> SPECIMENS:  Multiple cultures from the right ankle.
> 
> 
> 
> CLINICAL NOTE:  This is a 65-year-old woman who had a bimalleolar right ankle fracture dislocation treated by a doctor in Florida.  She had two operations, one for the initial ORIF, and another for revision ORIF secondary to hardware failure and loss of fixation.  The patient developed postoperative infection and was treated with antibiotics through a PICC line and then with oral antibiotics, and her soft-tissue wounds eventually healed, but she has pain now from prominent hardware.  The medial malleolar screw was backing out, and there are multiple loose screws in the distal fibula as well.  After a lengthy discussion regarding treatment options, it is elected to remove the hardware and perform multiple bone cultures to rule out infected nonunion. Depending on the results of the bone cultures devise more definitive care at a later date.  Informed consent was obtained prior to coming to the operating room.
> 
> 
> 
> DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed supine on the operating room table where general anesthetic was administered by the Anesthesia Department. One gram of Kefzol was administered intravenously.  The tourniquet was placed on the right calf.  The foot was prepped and draped in the usual sterile fashion, exsanguinated with an Esmarch, and the tourniquet inflated to 250 mmHg.  A 2 cm incision was made on the medial aspect of the ankle where the palpable screw in the medial malleolus was encountered very superficially in the ankle.  Dissection was carried out down to the medial malleolar cortex. The screw was removed, and curettes were used to culture the bone tissue.  This material was sent for culture sensitivity as well as histopathology to rule out osteomyelitis.  This wound was copiously irrigated and closed with 4-0 nylon suture.  An incision was then made on the lateral aspect of the ankle using the previous surgical incision from the tip of the fibula proximally about 6 cm and carried down sharply through skin and subcutaneous tissues and fascia and then directly down to the lateral fibular cortex where there was encountered two small fragment plates from a manufacturer not readily recognized, one anteriorly and one laterally.  The multiple screws were loosened and backing out into the soft tissue.  All screws were easily removed, and the plates were removed with an elevator.  Inspection then indicated that there was a fibrous nonunion of the distal fibular fracture as well with gross motion noted upon varus/valgus stress of the ankle.  Soft-tissue debridement was performed, and the wound was copiously irrigated and then closed with 0 Vicryl in the fascia, 2-0 Vicryl in subcutaneous tissues, and surgical skin staples in the skin.  Then, 0.5% plain Marcaine was infiltrated in the incisions for postoperative analgesia, and then the wounds were dressed with Adaptic, dry sterile dressings, and a well-padded, nonweightbearing, short-leg fiberglass cast.  The tourniquet was deflated, and the patient was awakened and transferred to the recovery room in stable condition having tolerated the procedure well



BE CAREFUL - there are  AAOS articles (june 2004 bulletin) that state you can only count 20680 once, even if 12 screws were removed

If the hardware was placed for bimal fx - then all hardware related to that fx is included in 20680 

There have also been many discussions in this forum regarding this same question, I believe they provided some links as well.


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## campy1961

Plaidman is correct you can charge for one if it is all regarding the ankle no matter how many screws/plates etc.  

Now if you had removal in the ankle and one in the wrist then you can charge for two.


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## maryanneheath

campy1961 said:


> Plaidman is correct you can charge for one if it is all regarding the ankle no matter how many screws/plates etc.
> 
> Now if you had removal in the ankle and one in the wrist then you can charge for two.



I agree with Plaidman and Campy.


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## armen

Here is the AAOS article:

*Hardware removal *

Q: The patient had a bimalleolar ORIF and, for whatever reason, a year or two later the physician removes the hardware. There are two plates and eight screws (four screws in each plate). Do you report: 

• 20680x10 for the two plates and eight screws? 

• 20680 just once because it is considered one internal device that was placed? 

• 20680x2 because you made two incisions to remove? 

A: Based on a discussion by the AAOS ICD-9 and CPT Coding Committee, removal of hardware used for a specific fracture type—regardless of the number of screws, plates, rods or incisions—would only be coded once. If there was an extraordinary of work involved (e.g., bone-buried screws, exceptional scar), then modifier -22 would be added with the usual accompanying note. 

Multiple use of 20680 would only be appropriate when the hardware removal was for another fracture unrelated to the first fracture (e.g.,ankle and humerus). Then modifier -59 would be used.


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## dpaige

*20680 x 2 ?*

I read the posts regarding hardware removal for a bimal ankle fracture and in doing further research I found this reply from Karen Zupko Associates, who I thought worked hand in hand with the AAOS.  So has something changed about how to code for this?

Denise Paige, CPC, COSC

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

August 25, 2011



Question:


Our surgeon recently had a case where he removed instrumentation from a bimalleolar fracture.

He states that he removed 2 plates (medial and lateral) and four screws for each plate. He made separate 2 incisions to remove each plate. Here are the code options I am considering but not sure which is correct?
1) 20680 twice because he had 2 separate fractures
2) 20680 five times for each side for a total of ten (screws and plate)
3) 20680 one time only because it was a fracture of the lower extremity?

I read Mary LeGrand's articles in the AAOS Now all the time and thought she might be able to help.


Answer:


Thanks for your question. The correct answer based on this scenario is to report 20680 twice because there are 2 separate fractures, 2 separate fixations. Code for the definitive procedure, which in this case is the removal of the plate (screws fixated the plate).

Report 20680 and 20680-59 to indicate the second hardware removal as a distinct separate procedure (separate location/separate incision).


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## lddavis

*ICD 10 code for this procedure note*

Actually, this is not an answer but a question.  For my curosity, what would be the ICD-10 code for the removal of the hardware?  If this was done in outpatient, what would you code the diagnosis?  Would this be an encounter for?


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## Aksarahsundberg

I would use Z47.2- encounter for removal of internal fixation device, as well as the original injury code for sequela.


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## raidaste

I'm curious why you would use the injury code with the sequel and not subsequent?


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