Orthopedic Coding Alert

Question: In a patient who has previously undergone ‘closed reduction and percutaneous pinning of right proximal humerus fracture’ and is now diagnosed a symptomatic hardware, our surgeon did a hardware removal. The procedure has been documented as ‘Hardware removalx3.’ The operative note reads as below:

"The patient was taken to the operating room and IV sedation was administered. Pins were palpated and incisions were made over each of three separate pins. There was one anterior, one far laterally, and one adjacent to the acromion. With blunt dissection, the pins were identified and extricated from the bone. The wounds were closed with simple sutures although the incision in the sagittal plane required figure-of-eight. Marcaine was injected. A dry sterile dressing was applied. The patient was woken up and taken to recovery room in stable condition."

What diagnosis code do we report for this condition?

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Answer: You need to confirm if the hardware removal was due to complications or was planned and routine. If done for complications, you report code 996.78 (Other complications due to other internal orthopedic device implant and graft) and 905.2 (Late effect of fracture of upper extremities). If it is a routine planned procedure, you report code V54.01 (Encounter for removal of internal fixation device).