The patient had previously suffered a displaced comminuted fracture of the right tibial shaft after falling approximately 30 feet. At that time, the patient had open reduction and internal fixation of the fracture. The patient is now presenting for open removal of fixation hardware due to loosening of the screws. The orthopedist stated that loosening/breakage of the screws is an expected outcome, not a complication of the surgery. What are the appropriate ICD-10-CM/PCS code assignments for this admission?
Assign code S82.251D, Displaced comminuted fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing. Assign also code W17.89XD, Fall from level to another, Subsequent encounter, to describe the external cause. Assign code 0QPG04Z, Removal of internal fixation device from right tibia, open approach, for the procedure performed.
When screws or other internal orthopedic implants are placed to align and link two bones that are supposed to move eventually, the screw or implant is expected to break or loosen. The screw is placed to hold the positions of the two bones while healing is occurring. Once weight bearing is initiated, the screw is expected to break or loosen. This is anticipated and expected, and in some cases the implant may have to be removed.
According to the official guidelines, the 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. If a patient presents for fracture aftercare, the fracture code with the 7th character “D” is assigned. Aftercare Z codes are not used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to describe subsequent care. Removal of external or internal fixation device is an example of subsequent care.