Wiki Retained hardware

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rjenn86

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I'm unsure as what code to use for the retained hardware. The assessment of the dictation reads:
left peroneal tenosynovitis, possible peroneus brevis tear.
#2 retained hardware of left fibula

I was thinking to use 996.40 but doesnt note complications and the reason for the hardware is from previous fx that was fixed years ago by diff doc. Thank you.
 
That's what I was going to use but right now he isnt stating that he will be removing it. Would I still use V54.01? Thank you
 
Yes, the impression reads:

left peroneal tenosynovitis, possible peroneus brevis tear.
#2 retained hardware of left fibula

Xray exam reads: 3 views left ankle obtain the office today reveal ankle mortise remains intact without significant arthrosis. There is no widening of the syndesmosis. The there are 3 retained screws in the fibula, the center screw extends approximately 3 mm posteriorly into the peroneal sheath.

Could I use 996.40 from what the xray exam is stating? Thank you
 
Healed: traumatic fx V15.51, healed pathological fx V13.51, healed stress fx V13.52 (listed under persons with potential health hazards related to personal & family hx.
 
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