Oral Surgery Coding & Reimbursement Alert

You could end up losing hundreds of dollars if you are unaware.

When a patient who has had interdental or internal fixation following open treatment of a fracture returns within the global period to undergo removal of the fixation, it is likely that you might not always report the removal as a separate procedure. In such circumstances, you might be losing out on ethical reimbursement if you are not aware when you can report this removal as a separate service.

Learn whether you can separately report hardware removal or not within the global period of the primary procedure from the following case study.

Case: The patient had open reduction internal fixation of two fractures and was placed in intermaxillary fixation for two weeks. Following the fixation period, the patient presented for removal of arch bar implants (maxillary arch bar hardware). The surgeon completely removed the arch bars and wire and wire fragments from the Erich arch bar and released the arch bar from the teeth.

A coding tip for 21470 (Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints) indicates that removal of a fixation device is not separately reportable. Does this mean that you cannot report the arch bar removal?

Know When to Report Removal as a Separate Service

Don’t dismiss removal codes, such as 20670 (Removal of implant; superficial [e.g., buried wire, pin or rod] [separate procedure]), as always included in the primary procedure.

Your surgeon will place arch bars to guide the occlusion for mandible repair. While your surgeon might sometimes remove the fixation at the end of the surgery, others are left in fixation for a month. When fixation is in place to allow union of the fracture, the removal at a later date can be separately reported. In such a case, you will have to use 20670 to report the hardware removal.

A CPT^® Assistant article in December 2007 also tells that you will have to use 20670 for removal of arch bars.

Coding tip: When you deal with removal of bone plates, the level of the implant moves from superficial to deep, and the code must also shift from 20670 to 20680 (… deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]).

While the above codes apply to internal fixation devices, CPT^® also gives you an option for reporting removal of an external fixation system. In this case you would use 20694 (Removal, under anesthesia, of external fixation system).

Reimbursement: Here’s the national average payment for each of the removal codes, based on Medicare’s fee schedule:

• 20670: $388.80 nonfacility or $152.36 facility total
• 20680: $634.59 nonfacility or $437.31 facility total
• 20694: $436.59 nonfacility or $348.55 facility total

Reality: Many oral and maxillofacial coders frequently encounter device removal in conjunction with fracture care. If you come across these procedures performed under other conditions, however, you need to look carefully at the device application code before reporting removal.

Don’t Led The Global Period Mislead You

You will have to report 20670 for arch bar removal at any time in the global or out of the global period. CPT^® Assistant, December 2007, confirms that this approach is correct.

“The removal of arch bars placed in the treatment of a fracture is a separately billable service and not included in the global package of the fracture repair surgery -- regardless of who (same surgeon or different surgeon) placed the arch bars in the first place,” concurs the American Association of Oral and Maxillofacial Surgery (AAOMS).

Some payers may require that you append a modifier if the surgeon performs the removal within the global period of the initial surgery. If the removal procedure is performed within the global period (90 days for 21470) you will have to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the post-operative period).

Select Appropriate POS

Some patients have the arch bars removed in the clinic and those who cannot tolerate the removal in your office will receive the service in the operating room.

Depending on the place of service (POS), use either office (11) or hospital operating room (21, Inpatient hospital) with 20670. When the procedure is performed in the office, it leads to better reimbursement versus when it is done in the hospital. Code 20670 has 10.82 nonfacility relative value units (RVUs, approximately $388.80) compared to 4.24 facility RVUs ($152.36), using the 2015 Medicare Physician Fee Schedule. The fee difference is because the facility would cover the supply cost if the physician performs the procedure in the facility, whereas the physician’s office would cover the cost when performed there.

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