Inpatient Facility Coding & Compliance Alert
Start With 20680 for Screw Extraction
Question: An orthopedic surgeon’s note states, “Previous incisions incised.....bluntly dissected down onto screw heads. Guidewires were placed. One screw was backed out, the other was advanced 7 mm. The lateral incision was incised approximately 2.5 cm on the fibula. Dissection carried down onto suture material, which was removed without difficulty. Wounds were irrigated and closed. Dx: prominent medial hardware.” Do I code anything other than 20680 for:
1. Removal of medial malleolar screw.
Pennsylvania Subscriber
Answer: You’re correct to begin by reporting the screw extraction with 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate). The advancement of the other screw would not be separately reportable because the surgeon used the same site/incision.
For the lateral side, you can report the removal of sutures with 15850 (Removal of sutures under anesthesia [other than local], same surgeon) or 15851 (Removal of sutures under anesthesia [other than local], other surgeon).
2. Advancement of secondary medial malleolar screw beneath the bone.
3. Removal of lateral sutures?
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