# presence of metal rod in leg



## tag60 (Apr 11, 2016)

Pt complaining of leg pain. She has a metal rod in right leg implanted after a leg fracture. Now she has pain in ankle and leg. Plan is to refer to Ortho.

Provider gives principal diagnosis of right leg pain. Should I also pick up a code to indicate the rod? I see codes for joint implants, but this is not a joint. I have considered Z76.9 (presence of functional implant, unspecified), but I'm just not sure what a "functional" implant is, and this one is specified, so that code doesn't seem to quite fit. Any advice/suggestions?

Thanks in advance!


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## bwolfe1 (Apr 11, 2016)

Look at code range T84.84, pain due to internal orthopedic prosthetic device, implants and grafts.


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## mitchellde (Apr 11, 2016)

If the provider does not document that the pain is due to the fracture or due to the implant, then it cannot be coded that way.  If the documentation mentions no issue with the rod or the previous injury, then you code only the leg pain.


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