Orthopedic Coding Alert

Question: My orthopedist documented that he removed three screws through three separate incisions at the proximal tibia. The op note states that the surgeon removed the first two screws through two small stab wounds and removed the third through a small incision over the screw. How should I code this? Kentucky Subscriber Answer: The answer to your question will depend on the screws- purpose when the orthopedist originally placed them. If the surgeon placed the screws to hold a plate in place, you should report 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]) to cover removing all the screws. Because the orthopedist placed the plate and screws as a single internal fixation device to treat one fracture, the single code represents the removal. But if the surgeon placed the individual screws without a plate to stabilize a fracture, you would report their removal as 20680 for the screw requiring the incision and two units of 20670-59 (... superficial [e.g., buried wire, pin or rod] [separate procedure]; distinct procedural service) for the screws removed through the stab incisions. You would report the screw removals through the stab incisions separately -- despite 20670's separate procedure status -- because the orthopedist made individual incisions to access and remove these screws. And you-ll need to append modifier 59 to 20670 to indicate these separate incisions to your payer. Keep in mind, however, that the American Academy of Orthopaedic Surgeons has stated that you should report the removal of hardware used to repair any given fracture with one unit of 20680, regardless of how many screws, plates, pins, etc., the physician removes. Consequently, you should check with your individual payers to determine their requirements for this situation.