Part B Insider (Multispecialty) Coding Alert
Not All Hardware Removals Are Payable
Question: My physician’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.
2. Advancement of secondary medial malleolar screw beneath the bone.
3. Removal of lateral sutures?
Answer: You should report the screw extraction with 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate). The advancement of other screw would not be separately reportable for 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).
Part B Insider (Multispecialty) Coding Alert
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